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WHO Library Cataloguing-in-Publication Data Neurological disorders : public health challenges. 1.Nervous system diseases. 2.Public health. 3.Cost of illness. I.World Health Organization. ISBN 92 4 156336 2 (NLM classication: WL 140) ISBN 978 92 4 156336 9
World Health Organization 2006 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specic companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Switzerland
iii
contents
Foreword Preface Acknowledgements Abbreviations Introduction Chapter 1 v vii ix xi 1
27 41
42 56 70 85 95 111 127 140 151 164
Chapter 4
177
183 185
186
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209
foreword
In the 19th century and at the beginning of the 20th, brain research belonged to many different areas that differed in methodology and targets: the morphological, the physiological and the psychological. The latter used to consider the brain as a black box where only the input and output were known but not at all the neuronal components and the way they interact with each other. At the beginning of the third millennium, due to prolonged ageing, neurodevelopmental disorders are growing and a much deeper knowledge of the brain is necessary. Scientic and technological research, from molecular to behavioural levels, have been carried out in many different places but they have not been developed in a really interdisciplinary way. Research should be based on the convergence of different interconnected scientic sectors, not in isolation, as was the case in the past. As this report demonstrates, the burden of neurological disorders is reaching a signicant proportion in countries with a growing percentage of the population over 65 years old. With this report go my best wishes that it be disseminated worldwide and that it receive the deserved attention of the Global Health Community in all the countries of the world.
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preface
Within its remit to provide leadership on all matters concerning health, one of the core functions of the World Health Organization (WHO) is to engage in partnerships where joint action is needed. WHO plays an important role in bringing crucial health-related topics to the agenda of policy-makers and health planners and in raising awareness of them among health-care professionals and all who have an interest in health matters. WHOs Department of Mental Health and Substance Abuse carries out this role for the three different sets of issues for which it is responsible: mental disorders, substance abuse and alcohol-related issues, and neurological disorders. Two recent publications have focused attention on its work. The world health report 2001 Mental health: new understanding, new hope is an advocacy instrument to shed light on the public health aspects of mental disorders, and the report Neuroscience of psychoactive substance use and dependence produced by the department in 2004 tackles the area of substance abuse and alcohol. We realized a similar exercise is needed in the eld of neurological disorders. The Global Burden of Disease study, the ongoing international collaborative project between WHO, the World Bank and the Harvard School of Public Health, has produced evidence that pinpoints neurological disorders as one of the greatest threats to public health. A clear message emerges that unless immediate action is taken globally, the neurological burden is expected to become an even more serious and unmanageable problem in all countries. There are several gaps in understanding the many issues related to neurological disorders, but we already know enough about their nature and treatment to be able to shape effective policy responses to some of the most prevalent among them. To ll the vast gap in the knowledge concerning the public health aspects of neurological disorders, this document Neurological disorders: public health challenges fulls two roles. On one hand, it provides comprehensive information to the policy-makers and on the other hand, it can also be used as an awareness-raising tool. The document has unique aspects that should be stressed. It is the result of a huge effort bringing together the most signicant international nongovernmental organizations working in the areas of various neurological disorders, both in a professional capacity and in caring for people affected by the conditions. It is the fruit of healthy interaction and collaboration between these organizations and WHO, with its network of country and regional ofces: health experts on
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acknowledgements 1
The following people, listed in alphabetical order, participated in the production of this document, under the guidance and with the support of Catherine Le Gals-Camus (Assistant Director-General, Noncommunicable Diseases and Mental Health, World Health Organization), to whom we express our sincere gratitude.
PROJECT TEAM
WRITING GROUP
Johan A. Aarli, Tarun Dua, Aleksandar Janca, Anna Muscetta
MANAGEMENT GROUP
Jos Manoel Bertolote, Tarun Dua, Aleksandar Janca, Frances Kaskoutas-Norgan, Anna Muscetta, Benedetto Saraceno, Shekhar Saxena, Rosa Seminario
EDITORIAL COMMITTEE
Johan A. Aarli, Giuliano Avanzini, Jos Manoel Bertolote, Hanneke de Boer, Harald Breivik, Tarun Dua, Nori Graham, Aleksandar Janca, Jrg Kesselring, Colin Mathers, Anna Muscetta, Leonid Prilipko, Benedetto Saraceno, Shekhar Saxena, Timothy J. Steiner
3.2 Epilepsy
Giuliano Avanzini (co-chair), Ettore Beghi, Hanneke de Boer (co-chair), Jerome Engel Jr., Josemir W. Sander, Peter Wolf
3.5 Neuroinfections
Reyna M. Duron, Hector Hugo Garcia, Ashraf Kurdi, Marco T. Medina (chair), Luis C. Rodriguez
3.9 Stroke
Julien Bogousslavsky (chair), Ming Liu, J. Moncayo, B. Norrving, A. Tsiskaridze, T. Yamaguchi, F. Yatsu
EXTERNAL REVIEWERS
Mario A. Battaglia, Donna Bergen, Gretchen Birbeck, Carol Brayne, Vijay Chandra, Amit Dias, M. Gourie-Devi, Rajendra Kale, Maria Lucia Lebrao, Itzhak Levav, Girish Modi, Theodore Munsat, Donald Silberberg (whole document); Daniel OConnor, Carlos Lima (Dementia); Satish Jain, Bryan Kies (Epilepsy); Anne MacGregor, Fumihiko Sakai (Headache disorders); Chris H. Polman, Ernie Willoughby (Multiple sclerosis); Peter G. E. Kennedy (Neuroinfections); Redda Tekle Haimanot (Neurological disorders associated with malnutrition); Ralf Baron, Maija Haanp (Pain associated with neurological disorders); Zvezdan Pirtosek, Bhim S. Singhal, Helio Teive (Parkinsons disease); Vladimir Hachinski, David Russell (Stroke); Vladan Bajtajic, Jacques Brotchi, Jeremy Ganz, Haldor Sletteb (Traumatic brain injuries)
PRODUCTION TEAM
Production coordination: Caroline Allsopp Editing: Barbara Campanini Design and layout: Reda Sadki Proofreading: Susan Kaplan Indexing: David McAllister Maps: Steve Ewart Printing coordination: Raphal Crettaz
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abbreviations 1
AD ADI AED AIDS ART BPSD CNS CRPS CSF CT DALY FAO EEG EMSP EPDA EUREPA GBD GDP GNI HAART HIV IBE IASP ICF ICH IHS ILAE MRI MS MSIF PD PET RTA SAH SMR TBI TIA UNESCO UNICEF UNFPA VaD WFN WFNS WHA WHO YLD YLL Alzheimers disease Alzheimers Disease International antiepileptic drug acquired immunodeciency syndrome antiretroviral therapy behavioural and psychological symptoms of dementia central nervous system complex regional pain syndrome cerebrospinal uid computerized tomography disability-adjusted life year Food and Agriculture Organization of the United Nations electroencephalography European Multiple Sclerosis Platform European Parkinsons Disease Association European Epilepsy Academy Global Burden of Disease gross domestic product gross national income highly active antiretroviral therapy human immunodeciency virus International Bureau for Epilepsy International Association for the Study of Pain International Classication of Functioning, Disability and Health intracerebral haemorrhage International Headache Society International League Against Epilepsy magnetic resonance imaging multiple sclerosis Multiple Sclerosis International Federation Parkinsons disease positron emission tomography road trafc accident subarachnoid haemorrhage standardized mortality ratio traumatic brain injury transient ischaemic attack United Nations Educational, Scientic and Cultural Organization United Nations Childrens Fund United Nations Population Fund vascular dementia World Federation of Neurology World Federation of Neurosurgical Societies World Headache Alliance World Health Organization years of healthy life lost as a result of disability years of life lost because of premature mortality
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introduction
One of the key constitutional responsibilities of the World Health Organization (WHO) is to foster partnership and collaboration among scientic and professional groups in order to contribute to the advancement of global health. To help prioritize health needs and design evidence-based health programmes globally, WHO initiates a large number of international projects and activities involving numerous governmental and nongovernmental organizations, health professionals and policy-makers.
The Global Burden of Disease (GBD) study, a collaborative endeavour of the World Health Organization (WHO), the World Bank and the Harvard School of Public Health, drew the attention of the international health community to the burden of neurological disorders and many other chronic conditions. This study found that the burden of neurological disorders was seriously underestimated by traditional epidemiological and health statistical methods that take into account only mortality rates but not disability rates. The GBD study showed that over the years the global health impact of neurological disorders had been underestimated (1). With awareness of the massive burden associated with neurological disorders came the recognition that neurological services and resources were disproportionately scarce, especially in low income and developing countries. Furthermore, a large body of evidence shows that policy-makers and health-care providers may be unprepared to cope with the predicted rise in the prevalence of neurological and other chronic disorders and the disability resulting from the extension of life expectancy and ageing of populations globally (2, 3). In response to the challenge posed by neurological disorders, WHO launched a number of global public health projects, including the Global Initiative on Neurology and Public Health whose purpose is to increase professional and public awareness of the frequency, severity and costs of neurological disorders and to emphasize the need to provide neurological care at all levels including primary health care. This global initiative has revealed a paucity of information on the burden of neurological disorders and a lack of policies, programmes and resources for their management (46).
introduction
Chapter 1
provides an overview of basic public health concepts and general principles as they apply to neurological disorders, including epidemiology and burden, health promotion, disease prevention, health policy, service provision and delivery of care, disability and rehabilitation, stigma, and education and training. Public health is dened as the science and practice of protecting and improving the health of the population through prevention, promotion, health education, and management of communicable and noncommunicable diseases including neurological disorders. In other words, public health is viewed as a comprehensive approach concerned with the health of the community as a whole rather than with medical health care that deals primarily with treatment of individuals. The focus of public health interventions could be primary, secondary or tertiary prevention. The above-mentioned concepts are illustrated by examples from the eld of neurological disorders. Public health aspects of individual neurological disorders covered by the report are discussed in greater detail in Chapter 3.
Each chapter contains a numerical list of references to works that are cited in the text. A second list, arranged alphabetically, suggests reading material that is recommended to give an overview of the subject matter of the section or chapter; some of the key references may be repeated in the reading list.
Chapter 2
contains a series of tables and graphs that provide projected estimates of the global burden of neurological disorders for 2005, 2015 and 2030. The illustrations are accompanied by a summary of the GBD methodology, observations on its limitations and brief commentaries on the ndings of the GBD study. The results are presented according to WHO regions, epidemiological subregions and World Bank income categories. Annex 1 lists WHO Member States and Annex 2 presents countries according to World Bank categories. Annex 3 provides the list of GBD cause categories, sequelae and case denitions used for calculation of estimates for neurological disorders. Annex 4 contains the GBD estimates for neurological disorders for 2005, 2015 and 2030.
Chapter 3
consists of 10 sections that focus on the public heath aspects of the specic neurological disorders covered by the report. Although notable differences exist between relevant public health issues for each neurological disorder, most sections cover the following topics: diagnosis and classication; etiology and risk factors; course and outcome; magnitude (prevalence, incidence, distribution by age and sex, global and regional distribution); disability and mortality; burden on patients families and communities; treatment, management and rehabilitation; delivery and cost of care; gaps in treatment and other services; policies;
Chapter 4
gives the conclusions and recommendations of the report, which are based on the following ndings. Neurological disorders are a signicant and increasing public health problem. Many of them can be either prevented or treated at a relatively low cost. Resources for neurological disorders are grossly inadequate in most parts of the world. Signicant inequalities in provision of neurological treatment and care exist between developing and developed countries. Stigma and discrimination against people with neurological disorders are ubiquitous and need to be eliminated through public education and global campaigns. Dignity of people with neurological disorders needs to be preserved and their quality of life improved. Long-term treatment and care of patients with chronic neurological disorders and conditions should be incorporated into primary care. Public health aspects of neurological disorders should be incorporated into undergraduate and postgraduate teaching and training curricula in neurology. More research on neurological disorders is needed and it should be facilitated through better funding, multidisciplinary approaches and international collaboration.
REFERENCES
1. Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA, Harvard School of Public Health on behalf of the World Health Organization and the World Bank, 1996 (Global Burden of Disease and Injury Series, Vol. I). 2. Sartorius N. Rehabilitation and quality of life. Hospital and Community Psychiatry, 1992, 43:1180 1181. 3. Gwatkin DR, Guillot M, Heuveline P. The burden of disease among the global poor. Lancet, 1999, 354:586589. 4. Janca A, Prilipko L, Costa e Silva JA. The World Health Organizations global initiative on neurology and public health. Journal of the Neurological Sciences, 1997, 145:12. 5. Janca A, Prilipko L, Costa e Silva JA. The World Health Organizations work on public health aspects of neurology. Journal of Neurology, Neurosurgery and Psychiatry, 1997, 63(Suppl 1):S67. 6. Janca A, Prilipko L, Saraceno B. A World Health Organization perspective on neurology and neuroscience. Archives of Neurology, 2000, 57:17861788. 7. Janca A et al. WHO/WFN survey on neurological services: a world-wide perspective. Journal of the Neurological Sciences, 2006, 247:2934. 8. Atlas: Country resources for neurological disorders 2004. Geneva, World Health Organization, 2004.
CHAPTER 1
principles
neurological disorders
in this chapter 8 Principles of public health 9 Epidemiology and burden 9 Health promotion and disease prevention 12 Health policy 14 16 20 22 23
public health
and
This chapter explains briey the principles of public health, epidemiology and the burden of disease, and the ways in which health promoService provision and delivery of care tion and disease prevention are achieved. It Disability and rehabilitation looks at risks to health and prevention stratStigma egies, and explains what health policy means. It then describes the goals and functions of Education and training health systems and in particular considers Conclusions service provision for neurological disorders. As many neurological disorders result in considerable morbidity, special attention is paid to disability and rehabilitation. The all-important part played by stigma in neurological disorders is assessed and, nally, education and training in neurology are discussed.
Many distinctions can be made between the practice of public health and that of clinical neurology. Public health professionals approach neurology more broadly than neurologists by monitoring neurological disorders and related health concerns of entire communities and promoting healthy practices and behaviours among them to ensure that populations stay healthy. Public health specialists focus on health and disease of entire populations rather than on individual patients, whereas neurologists usually treat one patient at a time for a specic neurological condition. These two approaches could be seen as being almost at the opposite ends of the health-care spectrum. What this chapter aims to do is to help build bridges between these two approaches and serve as a useful guide to the chapter that follows on the public health aspects of specic neurological disorders.
10
Figure
Disease prevention
The concept of disease prevention is more specic and comprises primary, secondary and tertiary prevention Health promotion (12). Primary prevention is dened as preventing the disease or stopping individuals from becoming at high risk. Universal and selective preventive interventions are included in primary prevention. Universal primary prevention targets the general public or a whole population group without an identied specic risk (e.g. iodine supplementation programmes to prevent neurological and other disorders caused by iodine deciency). Selective primary prevention targets individuals or subgroups of the population whose risk of developing disease is signicantly higher than average, as evidenced by biological, psychological or social risk factors (e.g. prevention of stroke through adequate management of hypertension, diabetes and hypercholesterolemia). Secondary prevention aims at decreasing the severity of disease or reducing risk level or halting progression of disease through early detection and treatment of diagnosable cases (e.g. ensuring drug compliance in the treatment of epilepsy). Tertiary prevention includes interventions that reduce premature death and disability, enhance rehabilitation and prevent relapses and recurrence of the illness. Rehabilitation may mitigate the effects of disease and thereby prevent it from resulting in impaired social and occupational functioning; it is an important public health intervention that has long been neglected by decision-makers. Moreover, rehabilitation is an essential aspect of any public health strategy for chronic diseases, including a number of neurological disorders and conditions such as multiple sclerosis, Parkinsons disease and the consequences of stroke or traumatic brain injury. Box 1.2 describes some examples illustrating the role of primary, secondary and tertiary preventive strategies for the neurological disorders discussed in this document.
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Health risks
Focusing on risks to health is a key to preventing any disease or injury. Many factors are relevant in prioritizing strategies to reduce risks to health. These include the extent of the threat posed by different risk factors, the availability of cost-effective interventions, and societal values and preferences. Risk assessment and estimates of the burden of disease resulting from different risk factors may be altered by many different strategies (13). The chain of events leading to an adverse health outcome includes proximal (or direct) causes and distal causes that are further back in the causal chain and act through a number of intermediary causal factors. It is therefore essential that the whole of the causal chain is considered in the assessment of risks to health. Trade-offs also exist between assessments of proximal and distal causes. As one moves further away from the direct causes of disease, there can be a decrease in causal certainty and diagnostic consistency, which is often accompanied by an increase in complexity of treatment. Distal causes, however, are likely to have an amplifying effect in that they can affect many different sets of proximal causes and so can potentially make large differences (14).
Prevention strategies
Prevention strategies and interventions designed to reduce or prevent a particular disease are of two types. In population or mass approaches, a whole population is asked to be involved in modifying their behaviour in some way (e.g. being immunized against poliomyelitis). In targeted or high-risk approaches, only high-risk individuals are involved, which necessitates some form of screening to identify those who are at high risk (e.g. HIV testing) (13). The distribution and determinants of risks in a population have major implications for strategies of prevention. A large number of people exposed to a small risk may generate many more cases than a small number exposed to a high risk. Thus, a preventive strategy focusing on high-risk individuals will deal only with the margin of the problem and will not have any impact on the considerable amount of disease occurring in the large proportion of people who are at moderate risk.
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Source: (15).
A different set of interventions can be used to achieve the same goal, and some interventions will reduce the burden associated with multiple risk factors and diseases. For example, interventions to reduce blood pressure, cigarette smoking and cholesterol levels reduce cerebrovascular and cardiovascular diseases and a number of others. The effect of using multiple interventions at the same time might be more than would be expected by summing the benets of carrying out the interventions singly. Risk reduction strategies are therefore generally based on a combination of interventions. For example, a CVD Risk Management Package has been developed by WHO for managing cardiovascular events (heart attacks and stroke). For cardiovascular disease prevention and control activities to achieve the greatest impact, a paradigm shift is required from the treatment of risk factors in isolation to comprehensive cardiovascular risk management. The risk management package facilitates this shift. It has been designed primarily for the management of cardiovascular risk in individuals found by opportunistic screening to have hypertension. It could be adapted, however, to be used with diabetes or smoking as entry points. The package is meant to be implemented in a range of health-care facilities in low and medium resource settings, in both developed and developing countries. For this reason it has been designed for three scenarios that reect the commonly encountered resource availability strata in such settings (16). The minimum conditions that characterize the three scenarios, in terms of the skill level of the health worker, the diagnostic and therapeutic facilities and the health services available, are described in Table 1.2.
HEALTH POLICY
Health policy usually refers to formal statements or procedures within institutions and governments that dene health priorities and actions aimed at improving peoples health. It can have a number of other goals in addition to preventing illness and promoting population health. In choos-
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Table 1.2 Characteristics of three scenarios in the WHO CVD Risk Management Package
Resource availability Human resources Equipment Scenario one Non physician health worker Stethoscope Blood pressure measurement device Measuring tape or weighing scale Optional: test tubes, holder, burner, solution or test strips for checking urine glucose Scenario two Medical doctor or specially trained nurse Stethoscope Blood pressure measurement device Measuring tape or weighing scale Test tubes, holder, burner, solutions or test strips for checking urine glucose and albumin Thiazide diuretics Beta blockers Angiotensin converting enzyme inhibitors Calcium channel blockers (sustained release formulations) (Reserpine and methyldopa if the above antihypertensives are unavailable) Aspirin Metformin (for rell) Scenario three Medical doctor with access to full specialist care Stethoscope Blood pressure measurement device Measuring tape or weighing scale Electrocardiograph Ophthalmoscope Urine analysis: fasting blood, sugar, electrolytes, creatinine, cholesterol and lipoproteins Thiazide diuretics Beta blockers Angiotensin converting enzyme inhibitors Calcium channel blockers (sustained release formulations) (Reserpine and methyldopa if the above antihypertensives are unavailable) Aspirin Insulin Metformin Glibenclamide Statins (if affordable) Angiotensin receptor blocker (if affordable) Access to full specialist care Maintenance and calibration of equipment
General drugs
Other facilities
Source: (16).
ing appropriate combinations of interventions, governments are also concerned with reducing poverty and other inequalities, with questions of human rights, acceptance by the community and political needs. They must also consider how different types of interventions can be incorporated into the health infrastructure available in the country, or how the infrastructure could be expanded or adapted to accommodate the desired strategies. This section discusses only health policy issues related to health promotion and disease prevention. A health policy paradox shows that preventive interventions can achieve large overall health gains for whole populations but might offer only small advantages to each individual. This leads to a misperception of the benets of preventive advice and services by people who are apparently in good health. In general, population-wide interventions have the greatest potential for prevention. For instance, in reducing risks from high blood pressure and cholesterol, shifting the mean values of whole populations will be more cost effective in avoiding future heart attacks and strokes than screening programmes that aim to identify and treat only those people with dened hypertension or raised cholesterol levels. Often both approaches are combined in one successful strategy.
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Service delivery
Organization of services for delivery of neurological care has an important bearing on their effectiveness. Because of their different social, cultural, political and economic contexts, countries have various forms of service organization and delivery strategies. The differing availability of nancial and human resources also affects the organization of services. Certain key issues, however, need to be taken into account for structuring services to provide effective care to people with neurological disorders. Depending upon the health system in the country, there is a variable mix of private and public provision of neurological care. The three traditional levels of service delivery are primary, secondary and tertiary care. Primary care includes treatment and preventive and promotional interventions conducted by primary care professionals. These vary from a general practitioner, nurse, other health-care staff and nonmedical staff to primary care workers based in rural areas. Primary care represents the point of entry for most people seeking care and is the logical setting where neurological disorders should begin to be addressed. Many potential benets exist for providing services through primary care. Users of primary care are more likely to seek early help because of the wide availability of facilities, their easy accessibility, cultural acceptability and reduced cost, thus leading to early detection of neurological disorders and better clinical outcome. Integration of neurological services into the primary care system needs to be a signicant policy objective in both developing and developed countries. Providing neurological care through primary care requires signicant investment in training primary care professionals to detect and treat neurological disorders. Such training should meet the specic practical training needs of different groups of primary care professionals such as doctors, nurses and community health workers. Preferably, ongoing training is needed to provide subsequent support for reinforcing new skills. In many countries, this has not been possible and thus suboptimal care is provided (18). Primary care centres are limited in their ability to adequately diagnose and treat certain neurological disorders. For the management of severe cases and patients requiring access to diagnostic and technological expertise, a secondary level of care is necessary. A number of neurological services may be offered in district or regional hospitals that form part of the general health system. Common facilities include inpatient beds in general medicine, specialist beds, emergency departments and outpatient clinics. The various types of services include consultation/liaison services, diagnostic facilities such as electroencephalography (EEG) and computerized tomography (CT), planned outpatient programmes, emergency care, inpatient care, intensive care, respite care, referral facilities for primary care services, multidisciplinary neurological care and rehabilitation programmes. These services require adequate numbers of general as well as specialist professionals who can also provide supervision and training in neurology to primary care staff.
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Rehabilitation
WHO denes rehabilitation as an active process by which those affected by injury or disease achieve a full recovery or, if a full recovery is not possible, realize their optimal physical, mental and social potential and are integrated into their most appropriate environment (19). Rehabilitation is one of the key components of the primary health-care strategy, along with promotion, prevention and treatment. While promotion and prevention primarily target risk factors of disease and
17
Rehabilitation strategy
Because of the complexity of rehabilitation based on the above-mentioned integrative model, rehabilitation services and interventions applying the rehabilitation strategy need to be coordinated along the continuum of care across specialized and non-specialized services, sectors and payers. Figure 1.2 illustrates the iterative problem-solving process sometimes called Rehab-CYCLE (20). The Rehab-CYCLE involves four steps: assess, assign, intervene and evaluate. The process is applied on two levels. The rst refers to the guidance along the continuum of care and the second to the provision of a specic service. From the guidance perspective, the assessment step inFigure 1.2 The Rehab-CYCLE cludes the identication of the persons problems and needs, the valuation of rehabilitation potential and prognosis and the Assessment denition of long-term service and goals of the intervention programme. The assignment step refers to the assignment to a service and an intervention programme. From the guidance perspective, the intervention step is not further specied. The Evaluation evaluation step refers to service and the achievement of the intervention goal. From the service perspective, the assessment step includes the identication of a persons problems, the review and poIntervention tential modication of the service or goals of the intervention programme and the denition of the rst Rehab-CYCLE goals and intervention targets. The assignment step refers to the assignment of health professionals and interventions to the intervention targets. The intervention step refers to the specication of the intervention techniques, the denition of indicator measures to follow the progress of the intervention, and the denition of target values to be achieved within a
Assignment
18
19
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STIGMA
Stigma has been dened as a deeply discrediting attribute that reduces a person to one who is in some way tainted and can therefore be denigrated. It is a pervasive problem that affects health globally, threatening an individuals psychological and physical well-being. It prevents individuals from coming forward for diagnosis and impairs their ability to access care or participate in research studies designed to nd solutions. Stigmatization of certain diseases and conditions is a universal phenomenon that can be seen across all countries, societies and populations. It refers to the relation between the differentness of an individual and the devaluation society places on that particular differentness. For stigmatization to be consistently effective, however, the stigmatized person must acquiesce to societys devaluation. When people with differentness internalize societys devaluation, they do not feel empowered to change the situation and the negative stereotypes become an accepted part of their concept of the disorder. The labelling, stereotyping, separation from others and consequent loss of status highlight the role of power relations in the social construction of stigma (22). People differentiate and label socially important human differences according to certain patterns that include: negative stereotypes, for example that people with epilepsy or other brain disease are a danger to others; and pejorative labelling, including terms such as crippled, disabled and epileptic. In neurology, stigma primarily refers to a mark or characteristic indicative of a history of neurological disorder or condition and the consequent physical or mental abnormality. For most chronic neurological disorders, the stigma is associated with the disability rather than the disorder per se. Important exceptions are epilepsy and dementia: stigma plays an important role in forming the social prognosis of people with these disorders. The amount of stigma associated with chronic neurological illness is determined by two separate and distinct components: the attribution of responsibility for the stigmatizing illness and the degree to which it creates discomfort in social interactions. An additional perspective is the socially structured one, which indicates that stigma is part of chronic illness because individuals who are chronically ill have less social value than healthy individuals. Some additional aspects and dimensions of stigma are given in Box 1.5. Stigma leads to direct and indirect discriminatory behaviour and factual choices by others that can substantially reduce the opportunities for people who are stigmatized. Whatever the mechanisms involved, stigma is an important public health problem. Stigma increases the toll of illness for many people with brain disorders and their families; it is a cause of disease, as people
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Training of physicians
The points to be taken into consideration in relation to education in neurology for physicians include: core curricula (undergraduate, postgraduate and others); continuous medical education; accreditation of training courses; open facilities and international exchange programmes; use of innovative teaching methods; training in the public health aspects of neurology. Teaching of neurology at undergraduate level is important because 2030% of the population are susceptible to neurological disorders (25). The postgraduate period of training is the most active and important for the development of a fully accredited neurologist. The following issues need consideration: mode of entry, core training programmes, evaluation of the training institutions, access to current literature, rotation of trainees between departments, and evaluation of the trainees during training and by a nal examination. The central idea is to build both the curriculum and an examination system that ensure the achievement of professional competence and social values and not merely the retention and recall of information. Neurological curricula vary considerably across countries. This is not necessarily undesirable because the curriculum must take into account local differences in the prevalence of neurological disorders. Some standardization in the core neurological teaching and training curricula and methods of demonstrating competency is desirable, however. The core curriculum should be designed to cover the practical aspects of neurological disorders and the range of educational settings should include all health resources in the community. The core curriculum also needs to reect national health priorities and the availability of affordable resources. Continuous medical education is an important way of updating the knowledge of specialists on an ongoing basis and providing specialist courses to primary care physicians. Specialist neurolo-
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CONCLUSIONS
Public health is the science and practice of protecting and improving the populations health through prevention, promotion, health education, control of communicable and noncommunicable diseases and monitoring of environmental hazards. It is a comprehensive approach that is concerned with the health of the community as a whole. Public health is community health: Health care is vital to all of us some of the time, but public health is vital to all of us all of the time (3). The mission of public health is to full societys interest in assuring conditions in which people can be healthy. The three core public health functions are: the assessment and monitoring of the health of communities and populations at risk to identify health problems and priorities; the formulation of public policies designed to solve identied local and national health problems and priorities; ensuring that all populations have access to appropriate and cost-effective care, including health promotion and disease prevention services, and evaluation of the effectiveness of that care. Public health comprises many professional disciplines such as medicine, nutrition, social work, environmental sciences, health education, health services administration and the behavioural sciences. In other words, public health activities focus on entire populations rather than on individual patients. Specialist neurologists usually treat individual patients for a specic neurological disorder or condition; public health professionals approach neurology more broadly by monitoring neurological disorders and related health concerns in entire communities and promoting healthy practices and behaviours so as to ensure that populations stay healthy. Although these approaches could be seen as two sides of the same coin, it is hoped that this chapter contributes to the process of building the bridges between public health and neurology and thus serves as a useful guide for the chapters to come.
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REFERENCES
1. Winslow CEA. The untilled eld of public health. Modern Medicine, 1920, 2:183191. 2. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, 1946. In: Basic documents, 45th ed. Geneva, World Health Organization, 2005 (http://whqlibdoc.who.int/hist/ofcial_records/constitution.pdf, accessed 2 October 2006). 3. Breslow L et al. Encyclopedia of public health. New York, Macmillan Reference, 2002. 4. Beaglehole R et al. Public health in the new era: improving health through collective action. Lancet, 2004; 363:20842086. 5. Wilkinson R, Marmot M, eds. The solid facts: social determinants of health. Geneva, World Health Organization, 2003. 6. Janca A, Prilipko L, Costa e Silva JA. The World Health Organizations global initiative on neurology and public health. Journal of the Neurological Sciences, 1997; 145:12. 7. Janca A, Prilipko L, Costa e Silva JA. The World Health Organizations work on public health aspects of neurology. Journal of Neurology, Neurosurgery and Psychiatry, 1997; 63(Suppl. 1): S6S7. 8. Janca A, Prilipko L, Saraceno B. A World Health Organization perspective on neurology and neuroscience. Archives of Neurology, 2000; 57:17861788. 9. Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA, Harvard School of Public Health on behalf of the World Health Organization and the World Bank, 1996 (Global Burden of Disease and Injury Series, Vol. I). 10. Tannahill A. What is health promotion? Health Education Journal, 1985; 44:167168. 11. The Bangkok Charter for Health Promotion in a Globalized World. Geneva, World Health Organization, 2005. 12. Leavell HR, Clark EG. Preventive medicine for the doctor in his community: an epidemiological approach, 3rd ed. New York, McGraw Hill, 1965. 13. The world health report 2002 Reducing risks, promoting healthy life. Geneva, World Health Organization, 2002. 14. Rose G. The strategy of preventive medicine. Oxford, Oxford University Press, 1992. 15. Liu B et al. Helmets for preventing injury in motorcycle riders. The Cochrane Database of Systematic Reviews, 2005, Issue 4. 16. WHO CVD-risk management package for low- and medium-resource settings. Geneva, World Health Organization, 2002. 17. The world health report 2000 Health systems: improving performance. Geneva, World Health Organization, 2000. 18. Institute of Medicine. Neurological, psychiatric, and developmental disorders. Meeting the challenge in the developing world. Washington, DC, National Academy Press, 2001. 19. International classication of functioning, disability and health. Geneva, World Health Organization, 2001. 20. Stucki G, Ewert T, Cieza A. Value and application of the ICF in rehabilitation medicine. Disability and Rehabilitation, 2002, 24:932938. 21. Kalsbeek WD et al. The National Head and Spinal Cord Injury Survey: major ndings. Journal of Neurosurgery, 1980; 53 (Suppl.):S1931. 22. Jacoby A, Snape D, Baker GA. Epilepsy and social identity: the stigma of a chronic neurological disorder. Lancet Neurology, 2005; 4:171178. 23. Jones EE et al. Social stigma: the psychology of marked relationships. New York, Freeman, 1984. 24. Jilek-Aall L et al. Psychosocial study of epilepsy in Africa. Social Science and Medicine, 1997; 45:783795. 25. European Federation of Neurological Societies. The Education Committee of EFNS: activities and work in progress. European Journal of Neurology, 2003; 10:205211.
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RECOMMENDED READING
Bergen DC. Preventable neurological diseases worldwide. Neuroepidemiology, 1998, 17:6773. Bergen DC, Silberberg D. Nervous system disorders: a global epidemic. Archives of Neurology, 2002; 59:11941196. Hewer RL. The economic impact of neurological illness on the health and wealth of the nation and of individuals. Journal of Neurology, Neurosurgery and Psychiatry, 1997, 63(Suppl. 1):1923. Institute of Medicine. Neurological, psychiatric, and developmental disorders. Meeting the challenge in the developing world. Washington, DC, National Academy Press, 2001. Menken M, Munsat TL, Toole JF. The Global Burden of Disease study: implications for neurology. Archives of Neurology, 2002; 57:418420. Singhal BS. Neurology in developing countries. A population perspective. Archives of Neurology, 1998; 55:10191021. Werner D. Disabled village children: a guide for health workers, rehabilitation workers and families. Berkeley, CA, The Hesperian Foundation, 1987. International classication of functioning, disability and health. Geneva, World Health Organization, 2001. Primary prevention of mental, neurological and psychosocial disorders. Geneva, World Health Organization, 1998. The Bangkok Charter for Health Promotion in a Globalized World. Geneva, World Health Organization, 2005. The world health report 2000 Health systems: improving performance. Geneva, World Health Organization, 2000. The world health report 2002 Reducing risks, promoting healthy life. Geneva, World Health Organization, 2002. WHO CVD-risk management package for low- and medium-resource settings. Geneva, World Health Organization, 2002.
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27
CHAPTER 2
global burden of
Ever-increasing demand for health services forces health planners to make choices about 29 Estimates and projections for neurological disorders resource allocation. Information on relative burden of various health conditions and risks 30 Data presentation to health is an important element in strategic 37 Conclusions health planning. What is needed to provide this information is a framework for integrating, validating, analysing, and disseminating the fragmentary, and at times contradictory, data that are available on a populations health, along with some understanding of how that populations health is changing over time.
The Global Burden of Disease (GBD) approach is one of the most widely used frameworks for information on summary measures of population health across disease and risk categories. The GBD framework is based on the use of a common metric to summarize the disease burden from diagnostic categories of the International Classication of Diseases and the major risk factors that cause those health outcomes. (4). The main purpose was to convert partial, often nonspecic, data on disease and injury occurrence into a consistent description of the basic epidemiological parameters. Many conditions including neuropsychiatric disorders and injuries cause considerable ill-health but no or few direct deaths. Therefore separate measures of survival and of health status among survivors needed to be combined to provide a single, holistic measure of overall population health. To assess the burden of disease, the 1990 GBD study used a timebased metric that measures both premature mortality (years of life lost because of premature mortality or YLL) and disability (years of healthy life lost as a result of disability or YLD, weighted by the severity of the disability). The sum of these two components,
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29
Cause categories
The cause categories used in the GBD study have four levels of disaggregation and include 135 specic diseases and injuries. At the rst level, overall mortality is divided into three broad groups of causes: Group I consists of communicable diseases, maternal causes, conditions arising in the perinatal period and nutritional deciencies; Group II encompasses the noncommunicable diseases (including neuropsychiatric conditions); and Group III comprises intentional and unintentional injuries. Deaths and health states are categorically attributed to one underlying cause using
30
Methodology
For the purpose of calculation of estimates of the global burden of disease, the neurological disorders are included from two categories: neurological disorders within the neuropsychiatric category, and neurological disorders from other categories. Neurological disorders within the neuropsychiatric category refer to the cause category listed in Group II under neuropsychiatric disorders and include epilepsy, Alzheimer and other dementias, Parkinsons disease, multiple sclerosis and migraine. Neurological disorders from other categories include diseases and injuries which have neurological sequelae and are listed elsewhere in cause category Groups I, II and III (10). The complete list used for calculation of GBD estimates for neurological disorders is given in Annex 3. Among the various neurological disorders discussed in this report, please note that for headache disorders, GBD includes migraine only (see Chapter 3.3). Also, GBD does not describe separately the burden associated with pain (see Chapter 3.7). There are also some diseases and injuries, which have neurological sequelae that have not been separately identied by the GBD study, and are not presented in this report; these include tuberculosis, HIV/AIDS, measles, low birth weight, birth asphyxia and birth trauma. The burden estimates for these conditions include the impact of neurological and other sequelae which are not separately estimated.
DATA PRESENTATION
This chapter summarizes data with the important ndings presented as charts and maps for DALYs, deaths, YLDs and prevalence as estimated for neurological disorders in the GBD study. The complete set of tables is given in Annex 4. The data are presented for the following variables.
DALYs Absolute numbers Percentage of total DALYs DALYs per 100 000 population Absolute numbers Percentage of total deaths Deaths per 100 000 population Absolute numbers Percentage of total YLDs YLDs per 100 000 population Total number of cases with different neurological disorders Prevalence per 1000 population of individual neurological disorders
Deaths
YLDs
Point prevalence
Please note that prevalence and YLDs are available for the neurological cause sequela combinations. These data are therefore provided for all neurological disorders within the neuropsychiatric category, cerebrovascular disease, combined for neuroinfections and neurological sequelae of infections (poliomyelitis, tetanus, meningitis, Japanese encephalitis, syphilis, pertussis, diphtheria, malaria), neurological sequelae associated with nutritional deciencies and neuropathies (proteinenergy malnutrition, iodine deciency, leprosy, and diabetes mellitus), and neurological sequelae associated with injuries (road trafc accidents, poisonings, falls, res, drownings, other unintentional injuries, self-inicted injuries, violence, war, and other intentional injuries) (see Table 2.1). While YLDs are separately estimated for each sequela, death (and hence YLLs and DALYs) are only estimated at the cause level, and for many causes it is not possible to describe sequelaspecic deaths. The tables for DALYs and deaths therefore only describe data for neurological cause categories (Table 2.2).
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Table 2.1 Neurological disorder groupings used for YLDs and prevalence data
Neurological disorders in neuropsychiatric category Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Disorders/injuries with neurological sequelae in other categories Cerebrovascular disease Neuroinfections Nutritional deciencies and neuropathies Neurological injuries
Table 2.2 Neurological disorder groupings used for DALYs and deaths data
Neurological disorders in neuropsychiatric category Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Disorders/injuries with neurological sequelae in other categories Cerebrovascular disease Poliomyelitis Tetanus Meningitis Japanese encephalitis
Income categories. The income categories are based on World Bank estimates of gross national income (GNI) per capita in 2001 (11). Each country is classied as low income (GNI US$ 745 or less), lower middle income (GNI US$ 7462975), upper middle income (GNI US$ 29769205), and high income (GNI $ 9206 or more). Annex 2 lists countries according to the World Bank income categories. The following tables and text describe the estimates for DALYs, deaths and YLDs for neurological disorders as estimated and projected for 2005, 2015 and 2030.
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Neurological disorders: public health challenges Estimates of disability-adjusted life years (DALYs)
Neurological disorders included in the neuropsychiatric category contribute to 2% of the global burden of disease, while cerebrovascular disease and some of the neuroinfections (poliomyelitis, tetanus, meningitis and Japanese encephalitis) contribute to 4.3% of the global burden of disease in 2005. Thus neurological disorders constitute 6.3% of the global burden of disease (see Table 2.4). The term neurological disorders henceforth used in this chapter includes those conditions in the neuropsychiatric category as well as in other categories. Figure 2.1 presents selected diseases as a percentage of total DALYs, in order to compare the burden constituted by them with that of neurological disorders. For example, HIV/AIDS and malignant neoplasm each constitute slightly over 5% of total burden. Table 2.4 presents the total number of DALYs in thousands associated with neurological disorders and as percentage of total DALYs for 2005, 2015 and 2030. Neurological disorders contribute to 92 million DALYs in 2005 projected to increase to 103 million in 2030 (approximately a 12% increase). While Alzheimer and other dementias are projected to show a 66% increase from 2005 to 2030, there is an estimated 57% decrease in DALYs associated with poliomyelitis, tetanus, meningitis and Japanese encephalitis combined.
Table 2.4 Number of DALYs for neurological disorders and as percentage of global DALYs projected for 2005, 2015 and 2030
Cause category No. of DALYs (000) Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Poliomyelitis Tetanus Meningitis Japanese encephalitis Total 7 308 11 078 1 617 1 510 7 660 50 785 115 6 423 5 337 561 92 392 2005 Percentage of total DALYs 0.50 0.75 0.11 0.10 0.52 3.46 0.01 0.44 0.36 0.04 6.29 No. of DALYs (000) 7 419 13 540 1 762 1 586 7 736 53 815 47 4 871 3 528 304 94 608 2015 Percentage of total DALYs 0.50 0.91 0.12 0.11 0.52 3.63 0.00 0.33 0.24 0.02 6.39 No. of DALYs (000) 7 442 18 394 2 015 1 648 7 596 60 864 13 3 174 2 039 150 103 335 2030 Percentage of total DALYs 0.49 1.20 0.13 0.11 0.50 3.99 0.00 0.21 0.13 0.01 6.77
Figure 2.1 Percentage of total DALYs for selected diseasesa and neurological disordersb
7 6
% of total DALYs
5 4 3 2 1 0
Neurological disorders
Tuberculosis
HIV/AIDS
Malignant neoplasms
Respiratory disease
Digestive diseases
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Table 2.5 DALYs per 100 000 population for neurological disorders globally and by World Bank income category, 2005
Cause category World (100 000 population) 113.4 172 25.1 23.4 118.9 788.4 1.8 99.7 82.9 8.7 1 434.3 Income category Low 158.3 90.7 15.1 20.1 114 662.5 2.6 228.6 143.2 13 1 448.1 Lower middle 80 150.7 19.7 23.3 106.8 1 061.2 1.6 10.8 51.2 9 1 514.3 Upper middle 139.2 166.9 17.5 24.9 147.1 612.2 0.9 1.3 39.7 0.4 1 150.1 High 51.3 457.3 70.8 32.5 146.3 592 0.6 0.1 10.7 0.6 1 362.2
Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Poliomyelitis Tetanus Meningitis Japanese encephalitis Total
As shown in Table 2.6, neurological disorders contribute most to the global burden of disease in the European Region (11.2%) and the Western Pacic Region (10%) compared with 2.9% in the African Region in 2005. DALYs per 100 000 population as estimated for 2005 are highest for Eur-C epidemiological subregion (2920) and lowest for Emr-B (751) (see Figure 2.4).
Figure 2.2 DALYs for individual neurological disorders as percentage of total neurological disorders
Cerebrovascular disease 55.0% Alzheimer and other dementias 12.0%
Figure 2.3 Neurological disorders as percentage of total DALYs for 2005, 2015 and 2030 across World Bank income category
14
2005
12 10 8 6 4 2 0 Low
2015
2030
Migraine 8.3% Poliomyelitis 0.1% Japanese encephalitis 0.6% Multiple sclerosis 1.6% Parkinson's disease 1.8% Meningitis 5.8% Epilepsy 7.9% Tetanus 7.0%
% of total DALYs
Lower middle
Upper middle
High
Income category
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Figure 2.4 DALYs per 100 000 population associated with neurological disorders by WHO region and mortality stratum, 2005
Region
Mortality DALYS per 100 000 stratum population for neurological disorders Afr-D Afr-E Amr-A Amr-B Amr-D Sear-B Sear-D Eur-A Eur-B Eur-C Emr-B Emr-D Wpr-A Wpr-B 1 536.73 1 361.41 1 214.18 1 135.56 1 251.09 750.50 1 480.39 1 463.53 1 665.33 2 920.22 1 089.68 1 377.09 1 543.28 1 470.80
The designations employed and the presentation of material on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dashed lines represent approximate border lines for which there may not yet be full agreement.
WHO 06.154
Table 2.6 Neurological disorders as percentage of total DALYs by WHO region, 2005
Cause category World (%) WHO region AFR (%) 0.46 0.10 0.02 0.03 0.13 1.11 0.00 0.77 0.24 0.00 2.86 AMR (%) 0.73 1.47 0.22 0.17 0.97 3.10 0.00 0.01 0.39 0.00 7.06 SEAR (%) 0.46 0.26 0.07 0.08 0.41 1.93 0.01 0.81 0.81 0.05 4.90 EUR (%) 0.40 2.04 0.30 0.20 0.80 7.23 0.00 0.00 0.24 0.00 11.23 EMR (%) 0.54 0.42 0.06 0.09 0.51 2.69 0.01 0.54 0.43 0.06 5.34 WPR (%) 0.44 1.32 0.15 0.15 0.73 6.81 0.01 0.10 0.24 0.09 10.04
Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Poliomyelitis Tetanus Meningitis Japanese encephalitis Total
0.50 0.75 0.11 0.10 0.52 3.46 0.01 0.44 0.36 0.04 6.29
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Estimates of deaths
Neurological disorders are an important cause of mortality and constitute 12% of total deaths globally (see Table 2.7). Within these, cerebrovascular diseases are responsible for 85% of the deaths due to neurological disorders (see Figure 2.5). Neurological disorders constitute 16.8% of the total deaths in lower middle income countries compared with 13.2% of the total deaths in high income countries (Figure 2.6). Among the neurological disorders, Alzheimer and other dementias are estimated to constitute 2.84% of the total deaths in high income countries in 2005. Cerebrovascular disease constitute 15.8%, 9.6%, 9.5% and 6.4% of the total deaths in lower middle, upper middle, high and low income countries respectively (Table 2.8).
Table 2.7 Deaths attributable to neurological disorders as percentage of total deaths, 2005, 2015 and 2030
Cause category Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Poliomyelitis Tetanus Meningitis Japanese encephalitis Total 2005 (%) 0.22 0.73 0.18 0.03 0.00 9.90 0.00 0.33 0.26 0.02 11.67 2015 (%) 0.21 0.81 0.20 0.03 0.00 10.19 0.00 0.23 0.17 0.01 11.84 2030 (%) 0.19 0.92 0.23 0.02 0.00 10.63 0.00 0.13 0.10 0.01 12.22
Figure 2.5 Deaths from selected neurological disorders as percentage of total neurological disorders
Cerebrovascular disease 85%
Figure 2.6 Neurological disorders as percentage of total deaths for 2005, 2015 and 2030 across World Bank income category
18 16 14
2005
2015
2030
% of total deaths
Japanese encephalitis 0.17% Multiple sclerosis 0.24% Parkinson's disease 1.55% Epilepsy 1.86% Meningitis 2.24%
Income category
Alzheimer and other dementias 6.28% Tetanus 2.83%
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Table 2.8 Deaths attributable to neurological disorders as percentage of total deaths by World Bank income category, 2005
Cause category World (%) Income category Low (%) 0.28 0.41 0.06 0.01 0.00 6.41 0.00 0.64 0.39 0.03 8.23 Lower middle Upper middle (%) (%) 0.17 0.34 0.18 0.02 0.00 15.81 0.00 0.04 0.18 0.01 16.77 0.20 0.46 0.15 0.05 0.00 9.64 0.00 0.01 0.16 0.00 10.67 High (%) 0.11 2.84 0.60 0.10 0.00 9.48 0.01 0.00 0.04 0.00 13.18
Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Poliomyelitis Tetanus Meningitis Japanese encephalitis Total
0.22 0.73 0.18 0.03 0.00 9.90 0.00 0.33 0.26 0.02 11.67
Table 2.9 YLDs per 100 000 population associated with neurological disorders and other diseases and injuries with neurological sequelae and as percentage of total YLDs projected for 2005, 2015 and 2030
Cause category/sequelae 2005 YLDs (100 000 population) Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Neuroinfections Nutritional deciencies and neuropathies Neurological injuries Total 64.7 147.4 17.7 20 118.9 176.8 98.4 194.9 425.4 1264.2 Percentage of total YLDs 0.73 1.66 0.20 0.23 1.34 2.00 1.11 2.20 4.80 14.27 2015 YLDs (100 000 population) 60.9 165.4 17.3 19.3 108.9 174.9 71.8 174.3 393.5 1186.3 Percentage of total YLDs 0.73 1.98 0.21 0.23 1.31 2.10 0.86 2.09 4.72 14.23 2030 YLDs (100 000 population) 55.6 203.9 17.1 18.4 96 177.8 45.6 133.9 360.8 1109.1 Percentage of total YLDs 0.71 2.60 0.22 0.23 1.22 2.27 0.58 1.71 4.60 14.14
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CONCLUSIONS
Burden of disease analyses as presented above are useful for informing health policy. They help in identifying not only the fatal but also the nonfatal outcomes for diseases that are especially important for neurological disorders. The above analyses demonstrate that neurological disorders cause a substantial burden because of noncommunicable conditions such as cerebrovascular disease, Alzheimer and other dementias as well as communicable conditions such as meningitis and Japanese encephalitis. As a group they cause a much higher burden than digestive diseases, respiratory diseases and malignant neoplasms. The GBD framework provides a common denominator that can be used to judge progress over time within a single country or region or relative performance across countries and regions. It is clearly demonstrated, by comparing 2005 data with the previous GBD study (2), that neurological disorders continue to represent a signicant burden. The GBD framework, for all its limitations,
Figure 2.7 Top ve causes of YLDs among neurological disorders, by World Bank income category, 2005
600
Figure 2.8 YLDs associated with neurological disorders by World Bank income category, 2005
13.7%
500 400 300 200 100 0 World Low Lower middle Upper middle High 31.7% Income category Low Lower middle Upper middle High World population (%) 41.9 35.2 8.2 14.7 8.3% 46.3%
Income category
Epilepsy Alzheimer and other dementias Migraine Cerebrovascular disease Neuroinfections Nutritional and neuropathies Neurological injuries
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REFERENCES
1. Murray CJL, Lopez AD, Jamison DT. The global burden of disease in 1990: summary results, sensitivity analyses, and future directions. Bulletin of the World Health Organization, 1994, 72:495508. 2. Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA, Harvard School of Public Health on behalf of the World Health Organization and The World Bank, 1996 (Global Burden of Disease and Injury Series, Vol. I). 3. Lopez AD, Murray CJL. The global burden of disease, 19902020. Nature Medicine, 1998, 4:12411243. 4. Barendregt JJ et al. A generic model for the assessment of disease epidemiology: the computational basis of DisMod II. Population Health Metrics, 2003, 1:e4. 5. Mathers CD et al. Global burden of disease in 2002: data sources, methods and results. Geneva, World Health Organization, 2004 (GPE Discussion Paper No. 54, rev. February 2004). 6. Mathers CD, Loncar D. Updated projections of global mortality and burden of disease, 20022030: data sources, methods and results. Geneva, World Health Organization, 2005 (Evidence and Information for Policy Working Paper). 7. Murray CJL, Lopez AD. Alternative projections of mortality and disability by cause, 19902020: Global Burden of Disease Study. Lancet, 1997, 349:14981504. 8. The world health report 2004 Changing history. Geneva, World Health Organization, 2004. 9. Mathers CD et al. Sensitivity and uncertainty analyses for burden of disease and risk factor estimates. In: Lopez AD et al., eds. Global burden of disease and risk factors. Washington, DC, The World Bank and Oxford University Press, 2006. 10. Mathers CD et al. Deaths and disease burden by cause: global burden of disease estimates for 2001 by World Bank country groups. Washington, DC, World Health Organization/World Bank/Fogarty International Center, United States National Institutes of Health, 2004 (Disease Control Priorities in Developing Countries (DCPP) Working Papers Series, No. 18; http://www.c.nih.gov/dcpp/wps.html, accessed 25 July 2005). 11. World development indicators. Washington, DC, The World Bank, 2003. 12. Chandra V et al. Neurological disorders. In: Jamison DT et al., eds. Disease control priorities in developing countries, 2nd ed. Washington, DC, The World Bank and Oxford University Press, 2006.
RECOMMENDED READING
Jamison DT et al., eds. Disease control priorities in developing countries, 2nd ed. Washington, DC, The World Bank and Oxford University Press, 2006. Lopez AD et al., eds. Global burden of disease and risk factors. Washington, DC, The World Bank and Oxford University Press, 2006. Mathers CD et al. Global burden of disease in 2002: data sources, methods and results. Geneva, World Health Organization, 2004 (GPE Discussion Paper No. 54, rev. February 2004). Mathers CD et al. Deaths and disease burden by cause: global burden of disease estimates for 2001 by World Bank country groups. Washington, DC, World Health Organization/World Bank/Fogarty International Center, United States National Institutes of Health, 2004 (Disease Control Priorities in Developing Countries (DCPP) Working Papers Series, No. 18; http://www.c.nih.gov/dcpp/wps.html, accessed 25 July 2005). Mathers CD, Loncar D. Updated projections of global mortality and burden of disease, 20022030: data sources, methods and results. Geneva, World Health Organization, 2005 (Evidence and Information for Policy Working Paper). Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA, Harvard School of Public Health on behalf of the World Health Organization and The World Bank, 1996 (Global Burden of Disease and Injury Series, Vol. I).
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41
CHAPTER 3
This chapter consists of 10 sections that focus on the public health aspects 111 3.6 Neurological disorders associated with of the common neurological disorders malnutrition as outlined in the box. Although nota127 3.7 Pain associated with neurological disorders ble differences exist between relevant public health issues for each neuro140 3.8 Parkinsons disease logical disorder, most sections cover 151 3.9 Stroke the following topics: diagnosis and classication; etiology and risk fac164 3.10 Traumatic brain injuries tors; course and outcome; magnitude (prevalence, incidence, distribution by age and sex, global and regional distribution); disability and mortality; burden on patients families and communities; treatment, management and rehabilitation; delivery and cost of care; gaps in treatment and other services; policies; research; and education and training.
95 3.5 Neuroinfections
42
3.1 Dementia
43 Etiology and risk factors 43 Course and outcome 44 Epidemiology and burden 46 50 52 54
Dementia is a syndrome caused by disease of the brain, usually of a chronic or progressive nature, in Treatment and care which there is disturbance of multiple higher cortical functions, including memory, thinking, orientaA public health framework tion, comprehension, calculation, learning capacConclusions and recommendations ity, language and judgement. Consciousness is not Case-studies clouded. Dementia mainly affects older people: only 2% of cases start before the age of 65 years. After this the prevalence doubles with every ve-year increment in age. Dementia is one of the major causes of disability in later life.
There are very many underlying causes of dementia. Alzheimers disease (AD), characterized by cortical amyloid plaques and neurobrillary tangles is the most common, accounting for one half to three quarters of all cases. Vascular dementia (VaD) is diagnosed when the brains supply of oxygenated blood is repeatedly disrupted by strokes or other blood vessel pathology, leading to signicant accumulated damage to brain tissue and function. The distinction between AD and VaD has been called into question, given that mixed pathologies are very common. Perhaps vascular damage is no more than a cofactor accelerating the onset of clinically signicant symptoms in people with AD. There are a few rare causes of dementia that may be treated effectively by timely medical or surgical intervention these include hypercalcaemia, subdural haematoma, normal pressure hydrocephalus, and deciencies of thyroid hormone, vitamin B12 and folic acid. For the most part, altering the progressive course of the disorder is unfortunately not possible. Symptomatic treatments and support can, however, transform the outcome for people with dementia and their caregivers. Alzheimer and other dementias have been reliably identied in all countries, cultures and races in which systematic research has been carried out, though levels of awareness vary enormously. In India, for example, while the syndrome is widely recognized and named, it is not seen as a medical condition. Indeed, it is often regarded as part of normal ageing (1). For the purpose of making a diagnosis, clinicians focus in their assessments upon impairment in memory and other cognitive functions, and loss of independent living skills. For carers and, arguably, for people with dementia, it is the behavioural and psychological symptoms of dementia (BPSD) that are most relevant. Nearly all studies indicate that BPSD are an important cause of caregiver strain. They are a common reason for institutionalization as the familys coping reserves become exhausted. Problem behaviours may include agitation, aggression, calling out repeatedly, sleep disturbance (daynight reversal), wandering and apathy. Common psychological symptoms include anxiety, depression, delusions and hallucinations. BPSD occur most commonly in the middle stage of dementia (see also the section on Course and outcome, below). Despite their signicance, there has been relatively little research into BPSD across cultures. One might anticipate that cultural and environmental factors could have a strong inuence upon both the expression
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44
Early stage
The early stage is often overlooked. Relatives and friends (and sometimes professionals as well) see it as old age, just a normal part of the ageing process. Because the onset of the disease is gradual, it is difcult to be sure exactly when it begins. The person may: have problems talking properly (language problems) have signicant memory loss particularly for things that have just happened not know the time of day or the day of the week become lost in familiar places have difculty in making decisions become inactive and unmotivated show mood changes, depression or anxiety react unusually angrily or aggressively on occasion show a loss of interest in hobbies and activities
Middle stage
As the disease progresses, limitations become clearer and more restricting. The person with dementia has difculty with day-to-day living and: may become very forgetful, especially of recent events and peoples names can no longer manage to live alone without problems is unable to cook, clean or shop may become extremely dependent on family members and caregivers needs help with personal hygiene, i.e. washing and dressing has increased difculty with speech shows problems with wandering and other behaviour problems such as repeated questioning and calling out, clinging and disturbed sleeping becomes lost at home as well as outside may have hallucinations (seeing or hearing things that are not there)
Late stage
The late stage is one of nearly total dependence and inactivity. Memory disturbances are very serious and the physical side of the disease becomes more obvious. The person may: have difculty eating be incapable of communicating not recognize relatives, friends and familiar objects have difculty understanding what is going on around them be unable to nd his or her way around in the home have difculty walking have difculty swallowing have bladder and bowel incontinence display inappropriate behaviour in public be conned to a wheelchair or bed
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46
47
48
49
Delivery of care
All over the world the family remains the cornerstone of care for older people who have lost the capacity for independent living, whether as a result of dementia or other mental disorder. However, stereotypes abound and have the potential to mislead. Thus, in developed countries with their comprehensive health and social care systems, the vital caring role of families, and their need for support, is often overlooked. This is true for example in the United Kingdom, where despite nuclear family structures and contrary to supposition, there is a strong tradition that persists today for local children to provide support for their inrm parents. Conversely, in developing countries the reliability and universality of the family care system is often overestimated. Older people are among the most vulnerable groups in the developing world, in part because of the continuing myths that surround their place in society (30). It is often assumed that their welfare is assured by the existence of the extended family. Arguably, the greatest obstacle to providing effective support and care for older persons is the lack of awareness of the problem among policy-makers, health-care providers and the community. Mythologizing the caring role of the family evidently carries the risk of perpetuating complacency. The previously mentioned 10/66 Dementia Research Groups multicentre pilot study was the rst systematic, comprehensive assessment of care arrangements for people with dementia in the developing world, and of the impacts upon their family caregivers (27 ). As in the EUROCARE study with data from 14 European countries (31), most caregivers in developing countries were older women caring for their husbands or younger women caring for a parent. Caring was associated with substantial psychological strain as evidenced by high rates of psychiatric morbidity and high levels of caregiver strain. These parameters were again very similar to those reported in the EUROCARE study. Some aspects, however, were radically different. People with dementia in developing countries typically live in large households, with extended families. Larger families were associated with lower caregiver strain; however, this effect was small and applied only where the principal caregiver was co-resident. Indeed, it seemed to operate in the opposite direction where the caregiver was non-resident, perhaps because of the increased potential for family conict. In many developing countries, traditional family and kinship structures are widely perceived as under threat from the social and economic changes that accompany economic development and globalization (30). Some of the contributing factors include the following: Changing attitudes towards older people. The education of women and their increasing participation in the workforce (generally seen as key positive development indicators); tending to reduce both their availability for caregiving and their willingness to take on this additional role. Migration. Populations are increasingly mobile as education, cheap travel and exible labour markets induce young people to migrate to cities and abroad to seek work. In India, Venkoba Rao has coined an acronym to describe this growing social phenomenon: PICA parents in India, children abroad. Push factors are also important. In the economic catastrophe of the 1980s, two million Ghanaians left the country in search of economic betterment; 63% of older persons have lost the support of one or more of their children who have migrated to distant places in Ghana or abroad. Older people are particularly vulnerable after displacement as a result of war or natural disaster.
50
Ensure availability of essential drugs in all health-care settings Make effective caregiver interventions generally available
Provide easier access to newer drugs (e.g. anticholinesterase agents) under public or private treatment plans
3. Give care in Establish the principle that the community people with dementia are best assessed and treated in their own homes Develop and promote standard needs assessments for use in primary and secondary care Initiate pilot projects on development of multidisciplinary community care teams, day care and short-term respite care Move people with dementia out of inappropriate institutional settings
Initiate pilot projects on integration of dementia care with general health care Provide community care facilities (at least 50% coverage with multidisciplinary community teams, day care, respite and inpatient units for acute assessment and treatment) According to need, encourage the development of residential and nursing-home facilities, including regulatory framework and system for staff training and accreditation
Develop alternative residential facilities Provide community care facilities (100% coverage) Give individualized care in the community to people with dementia
51
5. Involve communities, families and consumers 6. Establish national policies, programmes and legislation
Ensure fairness in access to primary and secondary health care services, and to social welfare programmes and benets
7. Develop human Train primary health-care resources workers Initiate higher professional training programmes for doctors and nurses in geriatric psychiatry and medicine Develop training and resource centres 8. Link with other Initiate community, school and sectors workplace dementia awareness programmes Encourage the activities of nongovernmental organizations
Create a network of national training centres for physicians, psychiatrists, nurses, psychologists and social workers
Extend occupational health services to people with early dementia Provide special facilities in the workplace for caregivers of people with dementia Initiate evidence-based mental health promotion programmes in collaboration with other sectors Develop advanced monitoring systems Monitor effectiveness of preventive programmes Extend research on the causes of dementia Carry out research on service delivery Investigate evidence on the prevention of dementia
Include dementia in basic health Institute surveillance for early information systems dementia in the community Survey high-risk population groups Conduct studies in primary health-care settings on the prevalence, course, outcome and impact of dementia in the community Institute effectiveness and costeffectiveness studies for community management of dementia
Based on overall recommendations from The world health report 2001 (32).
52
53
REFERENCES
1. Shaji KS et al. Caregivers of patients with Alzheimers disease: a qualitative study from the Indian 10/66 Dementia Research Network. International Journal of Geriatric Psychiatry, 2002, 18:16. 2. Shah A, Mukherjee S. Cross-cultural issues in measurement of BPSD. Aging and Mental Health, 2000, 4:244252. 3. Ferri CP, Ames D, Prince M. Behavioral and psychological symptoms of dementia in developing countries. International Psychogeriatrics, 2004, 16:441459. 4. Saunders AM et al. Association of apolipoprotein E allele e4 with late-onset familial and sporadic Alzheimers disease. Neurology, 1993, 43:14671472. 5. Nalbantoglu J et al. Predictive value of apolipoprotein E genotyping in Alzheimers disease: results of an autopsy series and an analysis of several combined studies. Annals of Neurology, 1994, 36:889895. 6. Breitner JC et al. Alzheimers disease in the National Academy of Sciences-National Research Council Registry of Aging Twin Veterans. III. Detection of cases, longitudinal results, and observations on twin concordance. Archives of Neurology, 1995, 52:763771. 7. Ott A et al. Prevalence of Alzheimers disease and vascular dementia: association with education. The Rotterdam study. BMJ, 1995, 310:970973. 8. Mortimer JA et al. Head trauma as a risk factor for Alzheimers disease: a collaborative re-analysis of case-control studies. EURODEM Risk Factors Research Group. International Journal of Epidemiology, 1991, 20(Suppl. 2):S28S35. 9. Mayeux R. Synergistic effects of traumatic head injury and apolipoprotein-epsilon 4 in patients with Alzheimers disease. Neurology, 1995, 45:555557. 10. Stern Y et al. Inuence of education and occupation on the incidence of Alzheimers disease. JAMA, 1994, 271:10041010. 11. Devanand DP et al. Depressed mood and the incidence of Alzheimers disease in the elderly living in the community. Archives of General Psychiatry, 1996, 53:175182. 12. Hofman A et al. Atherosclerosis, apolipoprotein E, and prevalence of dementia and Alzheimers disease in the Rotterdam Study. Lancet, 1997, 349:151154. 13. Ott A et al. Smoking and risk of dementia and Alzheimers disease in a population-based cohort study: the Rotterdam Study. Lancet, 1998, 351:18411843. 14. Skoog I et al. 15-year longitudinal study of blood pressure and dementia. Lancet, 1996, 347:11411145. 15. Kivipelto M et al. Midlife vascular risk factors and Alzheimers disease in later life: longitudinal, population based study. BMJ, 2001, 322:14471451. 16. Pandav RS et al. Hemoglobin levels and Alzheimer disease: an epidemiologic study in India. American Journal of Geriatric Psychiatry, 2004, 12:523526. 17. Ferri CP et al. Global prevalence of dementia: a Delphi consensus study. Lancet, 2005, 366:21122117. 18. Prince M. Methodological issues in population-based research into dementia in developing countries. A position paper from the 10/66 Dementia Research Group. International Journal of Geriatric Psychiatry, 2000, 15:2130. 19. Chandra V et al. Prevalence of Alzheimers disease and other dementias in rural India. The Indo-US study. Neurology, 1998, 51:10001008. 20. Hendrie HC et al. Prevalence of Alzheimers disease and dementia in two communities: Nigerian Africans and African Americans. American Journal of Psychiatry, 1995, 152:14851492. 21. Hendrie HC et al. Incidence of dementia and Alzheimer disease in 2 communities: Yoruba residing in Ibadan, Nigeria, and African Americans residing in Indianapolis, Indiana. JAMA, 2001, 285:739747. 22. Chandra V et al. Incidence of Alzheimers disease in a rural community in India: the Indo-US study. Neurology, 2001, 57:985989. 23. Prince M. Epidemiology of dementia. Vol. 3 Psychiatry. Abingdon, Medicine Publishing Company Ltd., 2004 (Part 12:1113). 24. Sadik K, Wilcock G. The increasing burden of Alzheimer disease. Alzheimer Disease and Associated Disorders, 2003, 17(Suppl. 3):S75S79. 25. Shah A, Murthy S, Suh GK. Is mental health economics important in geriatric psychiatry in developing countries? International Journal of Geriatric Psychiatry, 2002, 17:758764. 26. Zencir M et al. Cost of Alzheimers disease in a developing country setting. International Journal of Geriatric Psychiatry, 2005, 20:616622. 27. 10/66 Dementia Research Group. Care arrangements for people with dementia in developing countries. International Journal of Geriatric Psychiatry, 2004, 19:170177.
54
RECOMMENDED READING
For professionals Burns A, OBrien J, Ames D, eds. Dementia, 3rd ed. London, Hodder Arnold, 2005. Draper B, Melding P, Brodaty H, eds. Psychogeriatric service delivery: an international perspective. New York, Oxford University Press, 2004. For carers and non-medical readers Cayton H, Graham N, Warner J. Dementia Alzheimers and other dementias, 2nd ed. London, Class Publishing, 2003 (translated into several languages). Shenk D. The forgetting. Understanding Alzheimers disease: a biography of disease. London, Harper Collins, 2003. Bryden C. Dancing with dementia. My story of living positively with dementia. London, Jessica Publishers, 2005.
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56
3.2 Epilepsy
57 Course and outcome 58 Epidemiology 59 Burden on patients, families and communities 62 63 64 65 67
Epilepsy is a chronic neurological disorder affecting both sexes and all ages, with worldwide distribuTreatment, rehabilitation and cost tion. The term is also applied to a large group of Research conditions characterized by common symptoms Education and training called epileptic seizures, which may occur in the Partnerships within and beyond the health system context of a brain insult that can be systemic, toxic or metabolic. These events (called provoked or acute Conclusions and recommendations symptomatic seizures) are presumed to be an acute manifestation of the insult and may not recur when the underlying cause has been removed or the acute phase has elapsed.
Epilepsy has been dened as a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures, and by the neurobiological, cognitive, psychological and social consequences of this condition. The denition of epilepsy requires the occurrence of at least one epileptic seizure (1). An epileptic seizure is dened as a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain (1). These denitions recognize that a diagnosis of epilepsy implies the existence of a persistent epileptogenic abnormality that is present whether seizures occur or not, as well as that there may be consequences of this persistent abnormality other than the occurrence of seizures that can cause continuous disability between seizure occurrence (interictally). Because it is often difcult to identify denitively an enduring predisposition to generate epileptic seizures, a common operational denition of epilepsy is the occurrence of two or more non-provoked epileptic seizures more than 24 hours apart. Differential diagnosis of transient events that could represent epileptic seizures involves rst determining that the events are epileptic, then distinguishing between provoked epileptic seizures and a chronic epileptic condition. Febrile seizures in infants and young children and withdrawal seizures in alcoholics are common examples of provoked seizures that do not require a diagnosis of epilepsy. If seizures are recurrent, it is next necessary to search for an underlying treatable cause. If such a cause cannot be found, or if it is treated and seizures persist, then treatment of seizures is guided by diagnosis of the specic seizure type(s), and syndrome if present (see Box 3.2.1).
57
I. Generalized onset
A. B C D E Clonic and tonic seizures Absences Myoclonic seizure types Epileptic spasms Atonic seizures
III. Neonatal
58
EPIDEMIOLOGY
Incidence of epilepsy and unprovoked seizures
The annual incidence of unprovoked seizures is 33198 per 100 000, and the incidence of epilepsy is 23190 per 100 000 (3). The overall incidence of epilepsy in Europe and North America ranges from 24 and 53 per 100 000 per year, respectively (46). The incidence in children is eventually higher and even more variable, ranging from 25 to 840 per 100 000 per year, most of the differences being explained by the differing populations at risk and by the study design (3). In developing countries, the incidence of the disease is higher than that in industrialized countries and is up to 190 per 100 000 (3, 7). Although one might expect a higher exposure to perinatal risk factors, infections and traumas in developing countries, the higher incidence of epilepsy may be also explained by the different structure of the populations at risk, which is characterized by a predominant distribution of young individuals and a short life expectancy.
59
Prevalence of epilepsy
The overall prevalence of epilepsy ranges from 2.7 to 41 per 1000 population, though in the majority of reports the rate of active epilepsy (i.e. at least one seizure in the preceding ve years) is in the range 48 per 1000 (5, 10). The prevalence of active epilepsy is generally lower in industrialized countries than in developing countries, which may reect a lower prevalence of selected risk factors (mostly infections and traumas), a more stringent case verication, and the exclusion of provoked and unprovoked isolated seizures.
Mortality
The mortality rate of epilepsy ranges from 1 to 8 per 100 000 population per year, but international vital statistics give annual mortality rates of 12 per 100 000 (14). Based on a meta-analysis of studies investigating mortality in the past 100 years, the standardized mortality ratio (SMR) for epilepsy, which is the ratio between the deaths observed among patients with epilepsy and the deaths expected in a reference population with a similar age distribution, was found to range from 1.3 to 9.3 (15). The SMR for epilepsy ranges from 1.6 to 5.3 in children and adults and is inversely correlated with age (16). The higher SMRs may be partly explained by the inclusion of provoked seizures. The highest mortality risk in the youngest age groups can be interpreted in part in the light of the underlying epileptogenic conditions and the lower number of competing causes of death. It is extremely difcult to analyse the epilepsy death rate in the general population of a developing country because incidence studies of epilepsy are difcult to perform, death certicates are unreliable and often unavailable, and the cause of death is difcult to determine. Based on available data, it seems that the mortality rate of epilepsy in developing countries is generally higher than that reported in developed countries. These data cannot be generalized, however, as they have been obtained from selected populations (17 ).
60
Figure 3.2.1 Distribution of the global burden of epilepsy, by age group and level of economic development
100
90 80 70 60 50 40 30 20 10 0
18% 4% 7% 11% 29% 17% 22% 26% 31% 34% 37% 12% 78% 42% 35% 33% 29% 64% 55% 40% 42% 41% 40% 37% 56% 26%
32%
04
514
1529
3044
4559
6069
7079
80+
Total
Age group
Developed regions Low mortality developing regions High mortality developing regions
Source (22).
61
Figure 3.2.2 Attributable and avertable burden of epilepsy in an epidemiological subregion of Africa
100
25
50
80
100
62
Prevention
Currently, epilepsy tends to be treated once the condition is established, and little is done in terms of prevention. In a number of people with epilepsy the cause for the condition is unknown; prevention of this type of epilepsy is therefore currently not possible (33, 34). A sizeable number of people with epilepsy will have known risk factors, but some of these are not currently amenable to preventive measures. These include cases of epilepsy attributable to cerebral tumours or cortical malformations and many of the idiopathic forms of epilepsy. One of the most common causes of epilepsy is head injury, particularly penetrating injury. Prevention of the trauma is clearly the most effective way of preventing post-traumatic epilepsy, with use of head protection where appropriate (for example, for horse riding and motorcycling) (34). Epilepsy can be caused by birth injury, and the incidence should be reduced by adequate perinatal care. Fetal alcohol syndrome may also cause epilepsy, so advice on alcohol use before and during pregnancy is important. Reduction of childhood infections by improved public hygiene and immunization can lessen the risk of cerebral damage and the subsequent risk of epilepsy (33, 34). Febrile seizures are common in children under ve years of age and in most cases are benign, though a small proportion of patients will develop subsequent epilepsy. The use of drugs and other methods to lower the body temperature of a feverish child may reduce the chance of having a febrile convulsion and subsequent epilepsy, but this remains to be seen.
63
Treatment gap
Worldwide, the proportion of patients with epilepsy who at any given time remain untreated is large, and is greater than 80% in most low income countries (33, 34). The size of this treatment gap reects either a failure to identify cases or a failure to deliver treatment. In most situations, however, both factors will apply. Inadequate case-nding and treatment have various causes, some of which are specic to low income countries. They include peoples attitudes and beliefs, government health policies and priorities (or the lack of them), treatment costs and drug availability, as well as the attitude, knowledge and practice of health workers. In addition, there is clear scarcity of epilepsy-trained health workers in many low income countries. The lack of trained personnel and a proper health delivery infrastructure are major problems, which contribute to the overall burden of epilepsy. For instance, in most sub-Saharan countries there is no resident neurologist and there are no scanning facilities using magnetic resonance imaging (MRI) (35). This situation is found in many other resource-poor countries and is usually more acute in rural areas. The lack of trained specialists and medical facilities needs to be seen in the context of severe deciencies in health delivery that apply not only to epilepsy but also to the whole gamut of medical conditions. Training medical and paramedical personnel and providing the necessary investigatory and treatment facilities will require tremendous effort and nancial expenditure and will take time to achieve. The aim should be to provide high standards of epilepsy care with equitable access to all who need them throughout the world. There is a dearth of epilepsy services, trained personnel and AEDs, which contributes to a massive diagnostic and treatment gap in epilepsy that is more pronounced in low income countries. A huge effort is required to equalize care for people with epilepsy around the world. Improvement of the care delivery system and infrastructure alone are not a sufcient strategy but need to be supplemented by education of patients, their families and the general public.
RESEARCH
Despite the signicant advances in understanding epileptogenic mechanisms and in counteracting their pathological consequences, the problem still has to be faced of treating more effectively the severe epilepsies and of preventing their unfavourable evolution (37). So far, research has been unsuccessful in developing effective strategies capable of preventing the development of the pathogenic process, set in motion by different etiological factors, that leads ultimately to chronic epilepsies (38). To do so, it is important to take advantage of the results that are continuously being made available to the scientic community thanks to the synergy of basic and clinical multidisciplinary research. This means that the clinical applicability of neurobiological results should be evaluated, the way in which the new information can be translated into diagnostic and therapeutic terms should be assessed, and ad hoc guidelines and recommendations should be produced accordingly. In elaborating their health-care strategies, regional and national communities should not simply refer to the available scientic information, but should also contribute to it by means of their own
64
65
Objectives
To increase public and professional awareness of epilepsy as a universal and treatable brain disorder To raise epilepsy to a new plane of acceptability in the public domain To promote public and professional education about epilepsy To identify the needs of people with epilepsy at national and regional levels To encourage governments and departments of health to address the needs of people with epilepsy, including awareness, education, diagnosis, treatment, care, services and prevention
Strategy
To provide a platform for general awareness To assist departments of health in the development of national programmes on epilepsy
Activities
Organization of regional conferences followed by Regional Declarations Assessment of country resources for epilepsy worldwide Assistance with the development of regional reports Development of educational materials Coordination of demonstration projects
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67
5 6
REFERENCES
1. Fisher RS et al. Epileptic seizures and epilepsy. Denitions proposed by the International League against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia, 2005, 46:470472. 2. Engel J Jr. Report of the ILAE Classication Core Group. Epilepsia, 2006, 47:15581568. 3. Kotsopoulos IA et al. Systematic review and meta-analysis of incidence studies of epilepsy and unprovoked seizures. Epilepsia, 2002, 43:14021409. 4. Hauser WA, Annegers JF, Kurland LT. The incidence of epilepsy and unprovoked seizures in Rochester, Minnesota, 19351984. Epilepsia, 1993, 34:453468. 5. Forsgren L. Epidemiology and prognosis of epilepsy and its treatment. In: Shorvon S et al., eds. The treatment of epilepsy, 2nd ed. Malden, MA, Blackwell Science, 2004:2142. 6. Forsgren L et al. The epidemiology of epilepsy in Europe a systematic review. European Journal of Neurology, 2005, 12:245253. 7. Preux P-M, Druet-Cabanac M. Epidemiology and aetiology of epilepsy in sub-Saharan Africa. Lancet Neurology, 2005, 4:2131. 8. Bharucha NE, Shorvon SD. Epidemiology in developing countries. In: Engel J Jr, Pedley TA, eds. Epilepsy: a comprehensive textbook. Philadelphia, PA, Lippincott-Raven, 1997:105118. 9. Shamansky SL, Glaser GH. Socioeconomic characteristics of childhood seizure disorders in the New Haven area: an epidemiologic study. Epilepsia, 1979, 20:457474.
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69
RECOMMENDED READING
Annegers JF et al. Incidence of acute symptomatic seizures in Rochester, Minnesota: 19351984. Epilepsia, 1995, 36:327333. Beghi E. Aetiology of epilepsy. In: Shorvon SD et al., eds. The treatment of epilepsy, 2nd ed. Malden, MA, Blackwell Science, 2004:5063. Engel J Jr. Report of the ILAE Classication Core Group. Epilepsia, 2006, 47:15581568. Engel J Jr, Pedley TA. The comprehensive CD-ROM on epilepsy. Philadelphia, PA, Lippincott, Williams & Wilkins, 1999. Engel J Jr. Epilepsy: global issues for the practicing neurologist. New York, Demos Medical Publishing, 2005 (World Federation of Neurology: Seminars in Clinical Neurology). Hauser WA. Epidemiology of epilepsy. In: Gorelick PB, Alter M, eds. Handbook of neuroepidemiology. New York, Marcel Dekker, 1994:315353. Hauser WA, Hesdorffer DC, eds. Epilepsy: frequency, causes and consequences. New York, Demos Medical Publishing, 1990. Shorvon SD, Farmer PJ. Epilepsy in developing countries: a review of epidemiological, sociocultural and treatment aspects. Epilepsia, 1988, 29(Suppl. 1):S36S54. Tomson T. Mortality studies in epilepsy. In: Jallon P et al., eds. Prognosis of epilepsies. Paris, John Libbey, 2003:1221. Tomson T et al. Medical risks in epilepsy: a review with focus on physical injuries, mortality, trafc accidents and their prevention. Epilepsy Research, 2004, 60:116. Atlas: Epilepsy care in the world. Geneva, World Health Organization, 2005. The world health report 2001 Mental health: new understanding, new hope. Geneva, World Health Organization, 2001.
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Headache is a painful feature of a relatively small number of primary headache disorders, some of which are widespread and are often life-long conditions. Headache also occurs as a characteristic symptom of many other conditions; these are termed secondary headache disorders. Collectively, headache disorders are among the most common disorders of the nervous system, causing substantial disability in populations throughout the world.
Figure 3.3.1 Population-based epidemiological studies of of migraine Population-based epidemiological studies migraine
13.2 14.7 14.7 11.7 8.2 14.0 11.6 11.6 10.0 15.5 14.3 23.2 10.2 16.7
13.3 12.2 8.5 13.5 8.5 9.3 8.2 8.2 5.3 12.6 16.3
8.4 5.9
10.0
9.0
7.3 5.0
1 year prevalence %
4.0 (2 studies) 10.6 (6 studies 13.8 (9 studies) 12.6 (8 studies) 9.6 (10 studies)
WHO 06.156
Note: All studies used International Headache Society criteria (or reasonable modifications of these criteria) for diagnosing migraine and were conducted in general population or community-based adult samples of at least 500 participants. Numbers are estimated 1-year prevalences. Source: (3).
71
Despite the widespread and incapacitating nature of headache, it is underestimated in scope and scale, and headache disorders remain under-recognized and under-treated everywhere (1). Table 3.3.1 classifies headache disorders into primary, secondary, and neuralgias and other headaches, with their symptoms (2). The worldwide epidemiology of headache disorders is only partly documented. Populationbased studies have mostly focused on migraine (Figure 3.3.1) which, though the most frequently studied, is not the most common headache disorder. Others, such as the more prevalent tensiontype headache and the more disabling so-called chronic daily headache syndromes, have received less attention. Furthermore, few population-based studies exist for developing countries, where limited funding and large and often rural (and therefore less accessible) populations, coupled with the low profile of headache disorders compared with communicable diseases, prevent the systematic collection of information. Nevertheless, despite regional variations, headache disorders are thought to be highly prevalent throughout the world, and recent surveys add support to this belief. Sufficient studies have been conducted to establish that headache disorders affect people of all ages, races, income levels and geographical areas (Figure 3.3.2). Four of them three primary headache disorders and one secondary have particular public health importance.
Population-based epidemiological studies of headache disorders Figure 3.3.2 Population-based epidemiological studies of headache disorders a (all headache disorders or unspecied headache)
63.0 37.7 87.3 76.0 71.0 49.4 46.0 29.0 77.0
13.4
59.7
35.9
78.8
23.1
20.0
1 year prevalence %
a
21.6 (2 studies) 58.6 (5 studies) 56.1 (8 studies) 53.5 (3 studies) 50.0 (1 study) 41.3 (4 studies)
50.0
WHO 06.155
all headache disorders or unspecified headache. Note: All studies were conducted in general population or community-based adult samples of at least 500 participants. Numbers are estimated 1-year prevalences. Source: (3).
72
Secondary
Headache attributed to head and/or neck trauma Headache attributed to cranial or cervical vascular disorder Headache attributed to non-vascular intracranial disorder Headache attributed to a substance or its withdrawal Headache attributed to infection Headache attributed to disorder of homoeostasis Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures 12. Headache attributed to psychiatric disorder
13. Cranial neuralgias, central and primary facial pain and other headaches 14. Other headache, cranial neuralgia, central or primary facial pain
73
Tension-type headache
The mechanism of tension-type headache is poorly understood, though it has long been regarded as a headache with muscular origins (11). It may be stress related or associated with musculoskeletal problems in the neck. Tension-type headache has distinct subtypes. As experienced by very large numbers of people, episodic tension-type headache occurs, like migraine, in attack-like episodes. These usually last no more than a few hours but can persist for several days. Chronic tension-type headache, one of the chronic daily headache syndromes, is less common than episodic tension-type headache but is present most of the time: it can be unremitting over long periods. This variant is much more disabling. Headache in either case is usually mild or moderate and generalized, though it can be onesided. It is described as pressure or tightness, like a band around the head, sometimes spreading into or from the neck. It lacks the specic features and associated symptoms of migraine. Tension-type headache pursues a highly variable course, often beginning during the teenage years and reaching peak levels around the age of 3040 years. It affects three women to every two men. Episodic tension-type headache is the most common headache disorder, reported by over 70% of some populations (12), though its prevalence appears to vary greatly worldwide (3). In Japan, for example, Takeshima et al. (13) found 22% of the population to be affected, while Abduljabbar et al. (14) recorded only 3.1% with tension-type headache in a rural population of Saudi Arabia (though it was still the most common headache type). Lack of reporting and underdiagnosis were thought to be factors here, and it may be that cultural attitudes to reporting a relatively minor complaint explain at least part of the variation elsewhere. Chronic tension-type headache affects 13% of adults (3).
Cluster headache
Cluster headache is one of a group of primary headache disorders (trigeminal autonomic cephalalgias) of uncertain mechanism that are characterized by frequently recurring, short-lasting but extremely severe headache (1). Cluster headache also has episodic and chronic forms. Episodic cluster headache occurs in bouts (clusters), typically of 612 weeks duration once a year or two years and at the same time of year. Strictly one-sided intense pain develops around the eye once or more daily, mostly at night. Unable to stay in bed, the affected person agitatedly paces the room, even going outdoors, until the pain diminishes after 3060 minutes. The eye is red and watery, the nose runs or is blocked on the affected side and the eyelid may droop. In the less common chronic cluster headache there are no remissions between clusters. The episodic form can become chronic, and vice versa. Though relatively uncommon, probably affecting no more than 3 per 1000 adults, cluster headache is clearly highly recognizable. It is unusual among primary headache disorders in affecting six men to each woman. Most people developing cluster headache are 2030 years of age or older; once present, the condition may persist intermittently for 40 years or more.
Medication-overuse headache
Chronic excessive use of medication to treat headache is the cause of medication-overuse headache (15), another of the chronic daily headache syndromes. Medication-overuse headache is oppressive, persistent and often at its worst on awakening in the morning. A typical history begins with episodic headache migraine or tension-type headache. The condition is treated with an analgesic or other medication for each attack. Over time, headache episodes become more frequent, as does medication intake. In the end-stage, which not all patients reach, headache persists all day, uctuating with medication use repeated every few hours. This evolution occurs over a few weeks or much, much longer. A common and
74
Over-diagnosed headaches
Headache should not be attributed to sinus disease in the absence of other symptoms indicative of it. Many patients with headache visit an optician, but errors of refraction are overestimated as a cause of headache. Dental problems may cause jaw or facial pain but rarely headache.
75
BARRIERS TO CARE
Headache ought to be a public health concern, yet there is good evidence that very large numbers of people troubled, even disabled, by headache do not receive effective health care (2). For example, in representative samples of the general populations of the United States and the United Kingdom, only half the people identied with migraine had seen a doctor for headache-related reasons in the last 12 months and only two thirds had been correctly diagnosed (27 ). Most were solely reliant on over-the-counter medications, without access to prescription drugs. In a separate general-population questionnaire survey in the United Kingdom, two thirds of respondents with migraine were searching for better treatment than their current medication (28). In Japan, awareness of migraine and rates of consultation by those with migraine are noticeably lower (29). Over
76
Clinical barriers
Lack of knowledge among health-care providers is the principal clinical barrier to effective headache management. This problem begins in medical schools where there is limited teaching on the subject, a consequence of the low priority accorded to it. It is likely to be even more pronounced in countries with fewer resources and, as a result, more limited access generally to doctors and effective treatments.
Social barriers
Poor awareness of headache extends similarly to the general public. Headache disorders are not perceived by the public as serious since they are mostly episodic, do not cause death and are not contagious. In fact, headaches are often trivialized as normal, a minor annoyance or an excuse to avoid responsibility. These important social barriers inhibit people who might otherwise seek help from doctors, despite what may be high levels of pain and disability. Surprisingly, poor awareness of headache disorders exists among people who are directly affected by them. A Japanese study found, for example, that many patients were unaware that their headaches were migraine, or that this was a specic illness requiring medical care (31). The low consultation rates in developed countries may indicate that many headache sufferers are unaware that effective treatments exist. Again, the situation is unlikely to be better where resources are more limited.
Diagnosis
Committing sufcient time to taking a systematic history of a patient presenting with headache is the key to getting the diagnosis right. The history-taking must highlight or elicit description of the characteristic features of the important headache disorders described above. The correct diagnosis is not always evident initially, especially when more than one headache disorder is present, but the history should awaken suspicion of the important secondary headaches. Once it is established that there is no serious secondary headache, a diary kept for a few weeks to record
77
Realistic objectives
There are few patients troubled by headache whose lives cannot be improved by the right medical intervention with the objective of minimizing impairment of life and lifestyle (32). Cure is rarely a realistic aim in primary headache disorders, but people disabled by headache should not have unduly low expectations of what is achievable through optimum management. Medication-overuse headache and other secondary headaches are, at least in theory, resolved through treatment of the underlying cause.
6 7
78
THERAPEUTIC INTERVENTIONS
The purpose of pharmacotherapy of primary headache, once non-drug measures have been fully exploited, is to control symptoms so that the impact of the disorder on each individual patients life and lifestyle is minimized. This requires a therapeutic plan tailored for each patient, and patients with two or more coexisting headache disorders are likely to require separate plans for each disorder.
Migraine
Most people with migraine require drugs for the acute attack. These may be symptomatic or specic. The desirable goal of acute therapy with drugs currently available resolution of symptoms and full return of function within two hours is not attainable by all. When symptom control with best acute therapy is inadequate, it can be supplemented with prophylactic medication (34), usually for 46 months, aiming to reduce the number of attacks. General population surveys indicate that large numbers of people with migraine manage themselves, with no more than symptomatic over-the-counter remedies (27 ). For many this appears adequate. Simple oral analgesia acetylsalicylic acid or ibuprofen is used to best advantage in soluble formulations taken early because gastric stasis develops as the migraine attack progresses and this impedes absorption. A prokinetic antiemetic metoclopramide or domperidone enhances the analgesic effect by promoting gastric emptying and is most suitable for nausea and vomiting. When oral symptomatic therapy fails, it is logical to bypass the gut using a non-steroidal anti-inammatory drug such as diclofenac, with or without domperidone, given as rectal suppositories (35). Specic drugs triptans and, in certain circumstances, ergotamine tartrate should not be withheld from those who need them. There are specic contraindications to these drugs, particularly coronary disease (and multiple risk factors thereof) and uncontrolled hypertension, but triptans as a class show higher efcacy rates than symptomatic treatments. Population-based needs assessments suggest many more people with migraine should receive triptans than currently do. Cost has much to do with this, and this constraint must be more evident in resourcepoor countries where triptans are unlikely to be available. Denial of the best treatment available is difcult to justify for patients generally, however, and therefore for individuals: unnecessary pain and disability are the result. In addition, increasingly it is being demonstrated in developed countries that under-treatment of migraine is not cost effective: the time lost by sufferers and their carers is expensive, as are repeated consultations in the search for better therapy. On this basis some specialists believe that disability assessment should be the means to select patients to receive triptans. Where disability is the basis of choice, however, it should be noted that over 80% of people with migraine report disability because of it (36). Which triptan to choose is an individual matter because different patients respond differently to them: one may work where another does not. In countries where more than one is available, patients may reasonably try each in turn to discover which suits them best. Relapse (return of headache within 648 hours) in 2050% of patients who have initially responded is a troublesome limitation of triptans. A second dose is usually effective for relapse but, occasionally in some patients and often in a few, induces further relapse. This problem may underlie medication-overuse headache attributable to triptan overuse (37 ). Drugs in a range of pharmacological classes have limited but often useful prophylactic efcacy against migraine through mechanisms that are presumably not identical but are unclear. The choice
79
Tension-type headache
Reassurance and over-the-counter analgesics (acetylsalicylic acid or ibuprofen rather than paracetamol) (39) are sufcient for infrequent episodic tension-type headache. Most people with this condition manage themselves: episodic tension-type headache is self-limiting and, though it may be temporarily disabling, it rarely raises anxieties. If medication usage is on fewer than two days per week there is little risk of escalating consumption. People consult doctors because of episodic tension-type headache when it is becoming frequent and, in all likelihood, is no longer responding to painkillers. Long-term remission is then the objective of management, as it is for chronic tension-type headache. Symptomatic medication is contraindicated for tension-type headache occurring on more than two days per week: where it is already being taken at high frequency a diagnosis of chronic tension-type headache rather than medication-overuse headache cannot be made with condence. Whichever condition is present (and it can be both), frequently taken symptomatic medication must be withdrawn as the rst step (see below). Physiotherapy is the treatment of choice for musculoskeletal symptoms accompanying frequent episodic or chronic tension-type headache. In stress-related illness, lifestyle changes to reduce stress, and relaxation and/or cognitive therapy to develop stress-coping strategies, are the treatment mainstays. Prophylactic medication has a limited role. Amitriptyline is rst-line in most cases, withdrawn after improvement has been maintained for 46 months. Long-term remission is not always achievable, especially in long-standing chronic tension-type headache. A pain management clinic may be the nal option.
Cluster headache
Because of its relative rarity, cluster headache has a tendency to be misdiagnosed, sometimes for years. It is the one primary headache that may not be best managed in primary care, but the primary care physician has an important role not only in recognizing it at once but also in discouraging inappropriate treatments (tooth extraction is not infrequent).
Medication-overuse headache
Prevention is the ideal management of medication-overuse headache, which means avoidance of acute medication for headache on more than 23 days per week on a regular basis. Education is the key factor: many patients with medication-overuse headache are unaware of it as a medical condition (40). Once this disorder has developed, early intervention is important since the longterm prognosis depends on the duration of medication overuse (41). Treatment is withdrawal of the suspected medication(s). Although this will lead initially to worsening headache and sometimes nausea, vomiting and sleep disturbances, with forewarning and explanation it is probably most successful when done abruptly (42).
80
HEALTH-CARE POLICY
The volume of headache referrals to neurologists seen in developed countries is difcult to justify, and should not be repeated in countries where headache-related health services are being developed. The common headache disorders require no special investigation and they are diagnosed and managed with skills that should be generally available to physicians. Management of headache disorders therefore belongs in primary care for all but a very small minority of patients. Models of health care vary but, in most countries, primary care has an acknowledged and important role. It is a role founded on recognition that decisions in primary care take account of patient-related factors family medical history and patients individual expectations and values of which the continuity and long-term relationships of primary care generate awareness (43) while promoting trust and satisfaction among patients (44). Even in primary care, however, the needs of the headache patient are not met in the time usually allocated to a physician consultation in many health systems. Nurses and pharmacists can complement the delivery of health care. The evident burden of headache disorders on individuals and on society is sufcient to justify a strategic change in the approach to headache management (31, 45). In order to implement benecial change, public health policy in all countries must embrace the following elements. The prevalence of the common headache disorders in each region of the world needs to be known, through further epidemiological research where necessary, in order to gain a complete picture of headache disorders and their clinical, social and economic implications locally. This information, as it is accumulated, should be employed to combat stigma and increase public awareness of headache as a real and substantial health problem.
81
RESEARCH
Five research fronts are currently important in the eld of headache medicine. Basic research concentrates on elucidating disease mechanisms, particularly those that respond to environmental inuences and those with a genetic basis. The ndings will guide the development of new treatments. Pharmaceutical research and clinical trials support the translation of new discoveries into better treatments for people with headache disorders. Epidemiological research will establish the scope and scale of headache-related burden of illness around the world. The results will guide appropriate allocation of health-care resources by policy-makers. Epidemiological studies may also identify preventable risk factors for headache disorders. Health services research, backed by health economics studies, may show that the reallocation of resources towards improving health-care delivery offers greater benets for people with headache disorders by more effectively using treatments already available than the search for new pharmacological interventions. This is particularly so given the prevalence of medication misuse (both underuse and overuse). Community intervention studies may lead to better prevention of headache disorders. Outcomes research is needed to guide optimal health care and its delivery through organized health services. The importance of patient and public involvement in dening research objectives should be emphasized: lay people have experience and skills that complement those of researchers.
82
3 4
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83
REFERENCES
1. American Association for the Study of Headache and International Headache Society. Consensus statement on improving migraine management. Headache, 1998, 38:736. 2. Headache Classication Subcommittee of the International Headache Society. The international classication of headache disorders, 2nd ed. Cephalalgia, 2004, 24(Suppl. 1):1160. 3. Stovner LJ et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia (accepted for publication). 4. Ferrari MD. Migraine. Lancet, 1998, 351:10431051. 5. Scher AI, Stewart WF, Lipton RB. Migraine and headache: a meta-analytic approach. In: Crombie IK, ed. Epidemiology of pain. Seattle, WA, IASP Press, 1999:159170. 6. Steiner TJ et al. The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity. Cephalalgia, 2003, 23:519527. 7. Miranda H et al. Prevalence of headache in Puerto Rico. Headache, 2003, 43:774778. 8. Morillo LE et al. Prevalence of migraine in Latin America. Headache, 2005, 45:106117. 9. Celik Y et al. Migraine prevalence and some related factors in Turkey. Headache, 2005, 45:3236. 10. Ravishankar K. Barriers to headache care in India and efforts to improve the situation. Lancet Neurology, 2004, 3:564567. 11. Kellgren JH. Observations on referred pain arising from muscle. Clinical Science, 1938, 3:175190. 12. Rasmussen BK. Epidemiology of headache. Cephalalgia, 1995, 15:4568. 13. Takeshima T et al. Population-based door-to-door survey of migraine in Japan: the Daisen study. Headache, 2004, 44:819. 14. Abduljabbar M et al. Prevalence of primary headache syndrome in adults in the Qassim region of Saudi Arabia. Headache, 1996, 36:385388. 15. Diener H-C et al. Analgesic-induced chronic headache: long-term results of withdrawal therapy. Journal of Neurology, 1989, 236:914. 16. Srikiatkhachorn A, Phanthurachinda K. Prevalence and clinical features of chronic daily headache in a headache clinic. Headache, 1997, 37:277280. 17. Castillo J et al. Epidemiology of chronic daily headache in the general population. Headache, 1999, 39:190196. 18. Frishberg BM et al. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. Saint Paul, MN, American Academy of Neurology, 2001 (http://www.aan.com/professionals/practice/pdfs/gl0088.pdf). 19. Scher AI et al. Prevalence of frequent headache in a population sample. Headache, 1998, 38:497506. 20. Stovner LJ, Hagen K. Prevalence, burden and cost of headache disorders. Current Opinion in Neurology, 2006, 19:281285. 21. The world health report 2001 Mental health: new understanding, new hope. Geneva, World Health Organization, 2001:2224. 22. Lipton RB et al. The family impact of migraine: population-based studies in the US and UK. Cephalalgia, 2003, 23:429440. 23. Schwartz BS, Stewart WF, Lipton RB. Lost workdays and decreased work effectiveness associated with headache in the workplace. Journal of Occupational and Environmental Medicine, 1997, 39:320327. 24. Hopkins A, Menken M, De Friese GA. A record of patient encounters in neurological practice in the United Kingdom. Journal of Neurology, Neurosurgery and Psychiatry, 1989, 52:436438. 25. Wiles CM, Lindsay M. General practice referrals to a department of neurology. Journal of the Royal College of Physicians, 1996, 30:426431. 26. Laughey WF et al. Headache consultation and referral patterns in one UK general practice. Cephalalgia, 1999, 19:328329. 27. Hopkins A. Neurological services and the neurological health of the population in the United Kingdom. Journal of Neurology, Neurosurgery and Psychiatry, 1997, 63(Suppl. 1):S53S59. 28. Lipton RB et al. Patterns of health care utilization for migraine in England and in the United States. Neurology, 2003, 60:441448. 29. Dowson A, Jagger S. The UK Migraine Patient Survey: quality of life and treatment. Current Medical Research and Opinion, 1999, 15:241253. 30. Rasmussen BK, Jensen R, Olesen J. Impact of headache on sickness absence and utilisation of medical services: a Danish population study. Journal of Epidemiology and Community Health, 1992, 46:443446. 31. Headache disorders and public health: education and management implications. Geneva, World Health Organization, 2000. 32. Steiner TJ, Fontebasso M. Headache. BMJ, 2002, 325:881886.
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RECOMMENDED READING
American Association for the Study of Headache and International Headache Society. Consensus statement on improving migraine management. Headache, 1998, 38: 736. Frishberg BM et al. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. Saint Paul, MN, American Academy of Neurology, 2001 (http://www.aan.com/professionals/practice/pdfs/gl0088.pdf). Headache Classication Subcommittee of the International Headache Society. The international classication of headache disorders, 2nd ed. Cephalalgia, 2004, 24(Suppl. 1):1160. Lipton RB et al. The family impact of migraine: population-based studies in the US and UK. Cephalalgia, 2003, 23:429440. Olesen J et al., eds. The headaches, 3rd ed. Philadelphia, PA, Lippincott, Williams & Wilkins, 2006. Schwartz BS, Stewart WF, Lipton RB. Lost workdays and decreased work effectiveness associated with headache in the workplace. Journal of Occupational and Environmental Medicine, 1997, 39:320327. Steiner TJ. Lifting the burden: the global campaign against headache. Lancet Neurology, 2004, 3:204205. Steiner TJ, Fontebasso M. Headache. BMJ, 2002, 325:881886. Steiner TJ et al. The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity. Cephalalgia, 2003, 23:519527. Guidelines for all doctors in the diagnosis and management of migraine and tension-type headache. London, British Association for the Study of Headache, 2004 (http://www.bash.org.uk). Headache disorders and public health: education and management implications. Geneva, World Health Organization, 2000. The world health report 2001 Mental health: new understanding, new hope. Geneva, World Health Organization, 2001:2224.
85
Multiple sclerosis affects around 2.5 million people worldwide: it is one of the most common neurological disorders and cause 92 Research of disability of young adults, especially in Europe and North 93 Training America. There is a lack of epidemiological studies from Asia where the prevalence is reported to be low, though, with the 93 Conclusions and recommendations availability of more neurologists and magnetic resonance imaging, a larger number of patients are being diagnosed. Although some people experience little disability during their lifetime, up to 60% are no longer fully ambulatory 20 years after onset, with signicant implications for their quality of life and the nancial cost to society.
90 Prevention and treatment
Multiple sclerosis (MS) is an inammatory demyelinating condition of the central nervous system (CNS) that is generally considered to be autoimmune in nature. In people with MS, the immune trigger is unknown, but the targets are myelinated CNS tracts. In regions of inammation, breakdown of the bloodbrain barrier occurs and destruction of myelin ensues, with axonal damage, gliosis and the formation of sclerotic plaques. Plaques (MS lesions) may form in the CNS white matter in any location (and also in grey matter); thus, clinical presentations may be diverse. Continuing lesion formation in MS often leads to physical disability and, not infrequently, to cognitive decline.
86
Disability
Time
Disability Time
Disability Time
Source (2).
87
Prognostic factor
Although MS is an unpredictable condition, some studies have suggested that onset with sensory symptoms or optic neuritis may have a better outlook. It has also been shown that multisite presentations and poor recovery from an initial episode may indicate a worse outcome. Studies that have observed a difference by sex usually indicate that males experience a more severe course than females.
88
89
IMPACT
Multiple sclerosis has a profound impact on patients social roles and the well-being of their families. Varying degrees of functional decline typically accompany MS. Because the onset is usually at about 30 years of age, the loss in productivity of people with MS can be substantial. Such functional decline will often interfere with the opportunities for people with MS to perform their customary roles. For example, physical disability complicated by fatigue, depression and possibly cognitive impairment contributes to an unemployment rate as high as 70% among people with MS; to replace lost earnings, they frequently collect disability benets and social welfare. People with MS use more health-care resources than the general population (5). Together with their family members, they may also bear a nancial burden related to home and transport modications and the need for additional personal services. The socioeconomic impact of MS on the individual is well illustrated by a recent United Kingdom study (6). In this population-based survey of all known patients with MS and their relatives in the county of Hampshire, England, about 53% of those who were employed at the time of diagnosis gave up their jobs, and the standard of living of 37% of patients and their families declined as a direct result of the disease. The ability to continue in gainful employment or to maintain social contacts and leisure activities correlates with the course and severity of the disease and cognitive function. Most carers reported symptoms that clearly related to organic pathologies, anxiety and symptoms of depression. The occurrence of these symptoms was associated with disease severity. The professional careers of 57% of relatives were also adversely affected by the patients illness. The economic cost to society is also great (7 ). A recent economic analysis for the Australian MS Society (Acting Positively) illustrated the impact of the disease, which is considered typical (so far no global economic impact studies have been published). The Australian study found that the burden of the disease is likely to grow. Prevalence is expected to grow by 6.7% in the next ve years, faster than population growth attributable to demographic ageing. The total nancial costs of MS in 2005 are estimated at more than US$ 450 m (0.07% of GDP) and US$ 29 070 per person with MS, or US$ 23 per Australian per year. Lost productive capacity and the replacement value of informal community care are the two largest cost components (8). The following key economic factors were highlighted by the Australian study. Informal care for people with MS in the community represents 43% of total costs, with an average of 12.3 hours per week of informal care required per person with MS. Aids and modications for people with physical disability were estimated to represent a further 4.6% of total nancial costs. Production losses stemming from reduced work hours, temporary absences, early retirement and premature death are responsible for around 26% of total economic costs. Pharmaceuticals for people with MS, mainly beta-interferons, are estimated to represent 14% of total costs. Nursing home accommodation accounts for around 4.3% of total economic costs. Of the estimated 730 people with MS in (high care) nursing homes 37% are under 65 years of age. Other health-care costs including hospitalizations, specialist and primary care and allied health expenses account for 4.4%. Research is 1.9% of health expenditure, below the aver-
90
Neurorehabilitation
The philosophy of neurorehabilitation, which emphasizes patient education and self-management, is well suited to meet the complex and variable needs of MS (13). Neurorehabilitation aims to improve independence and quality of life by maximizing ability and participation. It has been dened by WHO as an active process by which those disabled by injury or disease achieve a full recovery or, if a full recovery is not possible, realize their optimal physical, mental and social potential and are integrated into their most appropriate environment. Together with Rehabilitation in Multiple Sclerosis, the European Multiple Sclerosis Platform (EMSP) developed useful guidance on this issue in their recommendations on MS rehabilitation services (14), one of the reference guidelines for their European Code of Good Practice in MS. The essential components of successful neurorehabilitation include expert multidisciplinary assessment, goal-oriented programmes and evaluation of impact on patient and goal achievement through the use of clinically appropriate, scientically sound outcome measures incorporating the patients perspective (14). While these principles are intuitively sound, the evidence underpinning multidisciplinary assessment and goal-orientated programmes is weak. Fundamental to the provision of robust
91
Service delivery
Evaluating service delivery may be considered the most important and relevant issue in the management of MS. This is because it incorporates acute hospital and neurorehabilitation services with community-based activities and has to bring together medical and social services in a way that meets the complex and ever-changing needs of the person with MS. Ideally, most services should be community-based with supporting expertise from the acute hospital or rehabilitation centre at times of particular need (such as at diagnosis or during a severe relapse) or complexity (when multiple symptoms interact and intensive inpatient rehabilitation is required). The optimum method of service delivery has not yet been dened, and little comparison has been made of existing services. A recently published study (17 ) compared two forms of service delivery in a randomized controlled trial. One group received what was described as hospital home care, in which patients remained in the community but had immediate access to the hospital-based multidisciplinary team when required, while the other group received routine care. No difference was seen in the level of disability between the two groups after 12 months, but the hospital home care patients, who were more intensely treated, had signicantly less depression and improved quality of life. There continue to be major problems worldwide in delivering a model of care that provides truly coordinated services. There is serious inequity of service provision both within and across countries, and an inordinate and unacceptable reliance on family and friends to provide essential care. Establishing guidance, such as has been done by the National Institute for Clinical Excellence (18), is a step forward but a global initiative such as that of the Multiple Sclerosis International Federation (MSIF) to promote the quality of life of people with MS may be more effective (19). The key challenge will be ensuring the translation of these guidelines into practice. Delivery of care to people with MS varies signicantly around the world. In part this reects the differences in incidence and therefore the relative importance afforded to the disease within a countrys health system. Given the importance of expensive diagnostic equipment (scanners) and the cost of the existing treatments, however, the variation also reects different national income levels. In the developed countries, the cost of the treatment is borne by the government or insurance companies but in some regions the patients have to pay for drugs, making it difcult for them to take advantage of emerging new treatments. The delivery of care for people with long-term illnesses is becoming increasingly patient centred, and a culture of treatment by interdisciplinary teams is emerging. Within this model, the aim is to offer patients a seamless service, which typically involves bringing together various health professionals including doctors, nurses, physiotherapists, occupational therapists, speech and language therapists, clinical psychologists and social workers. Other professionals with expertise in treating neurologically disabled people cover dietetics, continence advisory and management services, pain management, chiropody, podiatry and ophthalmology services.
92
Treatment gap
There is no doubt that a signicant treatment gap exists in approaches to MS between countries (and possibly within countries). Until a cure is found, people with MS have to rely on reducing the inammation during an acute phase by the use of corticosteroids and providing symptomatic relief. The disease-modifying agents such as beta-interferon and glatiramer acetate can be offered to decrease the relapses and disease burden. Ideally, this treatment programme requires early diagnosis and adequate human resources and equipment. The situation is especially problematic in the developing countries, as often equipment such as an MRI scanner is not available or is too expensive. The disease-modifying agents are also costly and beyond the reach of many patients. In addition, rehabilitation centres for people with MS are not available. A further illustration of the treatment gap between rich and less developed countries in their treatment of MS is apparent from data currently being collected by WHO, the MSIF and the EMSP. These data, which will in time be integrated into an international comparative and interactive database (MSIF/WHO Atlas of MS and European Map of MS), have been sourced by surveying neurologists and patient organizations across 98 geographically and economically diverse countries. For example, in response to the key treatment question What percentage of people with MS who full the clinical prescription criteria for disease-modifying drugs [in your country] receive treatment? the average answer from 15 responding members of the European Union was 64%. This compares with (for example) 45% for Brazil, 50% for the Russian Federation, 1015% for Turkey and less than 5% for India.
RESEARCH
As with many neurological diseases, MS is extremely difcult to study. Even after several decades of intense research activity, it remains a mysterious condition with no known pathogen or accepted determinants of its severity or course. Nonetheless, optimism amongst the MS research community is high. Advances in non-invasive investigative techniques, particularly MRI, have led
93
TRAINING
There is a specic lack of public and professional awareness of the dimension of MS in the domains of epidemiology and impact of disease on individuals, carers and society, including impact on individual loss of independence, and cost of long-term care. In particular, the chronic progressive nature of the condition must be better conveyed to all. MSlF, through its member organizations, has proven very effective and capable of concerted action in the eld of patient and lay public education.
94
REFERENCES
1. Polman CH et al. Diagnostic criteria for multiple sclerosis: 2005 revisions to the McDonald criteria. Annals of Neurology, 2005, 58:840846. 2. Update on medical management of multiple sclerosis to staff of the Multiple Sclerosis Society of New South Wales. Lidcombe, Multiple Sclerosis Society of New South Wales, 2003. 3. Warren S, Warren KG. Multiple sclerosis. Geneva, World Health Organization, 2001. 4. Rosati G. The prevalence of multiple sclerosis in the world: an update. Neurological Sciences, 2001, 22:117139. 5. Sternfeld L. Utilization and perceptions of healthcare services by people with MS. New York, US National Multiple Sclerosis Society, 1995. 6. Hakim EA et al. The social impact of multiple sclerosis a study of 305 patients and their relatives. Disability and Rehabilitation, 2000, 22:288293. 7. Kobelt G, Pugliatti M. Cost of multiple sclerosis in Europe. European Journal of Neurology, 2005, 12(Suppl. 1):6367. 8. Acting positively: strategic implications of the economic costs of multiple sclerosis in Australia. Canberra, Access Economics Pty Ltd. for Multiple Sclerosis Australia, 2005. 9. Polman CH et al. Multiple sclerosis The guide to treatment and management. London, Multiple Sclerosis International Federation, 2006. 10. Chataway J et al. Treating multiple sclerosis relapses at home or in hospital: a randomised controlled trial of intravenous steroid delivery. Lancet Neurology, 2006, 5:565571. 11. Multiple Sclerosis Therapy Consensus Group. Escalating immunotherapy of multiple sclerosis. Journal of Neurology, 2004, 251:13291339. 12. Henze T, Rieckmann P, Toyka KV and Multiple Sclerosis Therapy Consensus Group of the German Multiple Sclerosis Society. Symptomatic treatment of multiple sclerosis. European Neurology, 2006, 56:78105. 13. Thompson AJ. Neurorehabilitation in multiple sclerosis: foundations, facts and ction. Current Opinion in Neurology, 2005, 18:267271. 14. Recommendations on rehabilitation services for persons with multiple sclerosis in Europe. Brussels, European Multiple Sclerosis Platform and Rehabilitation in Multiple Sclerosis, 2004 (European Code of Good Practice in Multiple Sclerosis). 15. Crayton H, Heyman R, Rossman H. A multimodal approach to managing the symptoms of multiple sclerosis. Neurology, 2004, 11(Suppl. 5):S12S18. 16. Thompson AJ et al. Clinical management of spasticity (Editorial review). Journal of Neurology, Neurosurgery and Psychiatry, 2005, 76:459463. 17. Pozzilli C et al. Home based management in multiple sclerosis: results of a randomised controlled trial. Journal of Neurology, Neurosurgery and Psychiatry, 2002, 73:250255. 18. Multiple sclerosis: management of multiple sclerosis in primary and secondary care. London, National Institute for Health and Clinical Excellence, 2003. 19. Principles to promote the quality of life of people with multiple sclerosis. London, Multiple Sclerosis International Federation, 2005.
RECOMMENDED READING
Compston A et al., eds. Multiple sclerosis. Amsterdam, Elsevier, 2005. Goodin DS et al. Disease modifying therapies in multiple sclerosis: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the MS Council for Clinical Practice Guidelines. Neurology, 2002, 58:169178. Joy JE, Johnston RB, eds. Multiple sclerosis: current status and strategies for the future. Washington, DC, Institute of Medicine, 2001. Murray TJ. Multiple sclerosis: the history of a disease. New York, Demos Medical Publishing, 2005. Polman CH et al. Multiple sclerosis The guide to treatment and management. London, Multiple Sclerosis International Federation, 2006. Warren S, Warren KG. Multiple sclerosis. Geneva, World Health Organization, 2001. Multiple sclerosis: management of multiple sclerosis in primary and secondary care. London, National Institute for Health and Clinical Excellence, 2003. Principles to promote the quality of life of people with multiple sclerosis. London, Multiple Sclerosis International Federation, 2005. Recommendations on rehabilitation services for persons with multiple sclerosis in Europe. Brussels, European Multiple Sclerosis Platform and Rehabilitation in Multiple Sclerosis, 2004 (European Code of Good Practice in Multiple Sclerosis).
95
3.5 Neuroinfections
96 Viral diseases 100 Mycobacterial and other bacterial diseases 103 Parasitic diseases
Infectious diseases that involve the nervous system affect millions of people around the world. They constitute the sixth 108 Conclusions and recommendations cause of neurological consultation in primary care services and are reported globally by a quarter of WHOs Member States and by half the countries in some parts of Africa and South-East Asia. Neuroinfections are of major importance since ancient times and, even with the advent of effective antibiotics and vaccines, still remain a major challenge in many parts of the world, especially in developing nations.
107 Implications and prevention
Approximately 75% of the world population live in developing countries where the worst health indicators are found. Their major health problems are generally related to warm climate, overcrowding, severe poverty, illiteracy and high infant mortality which induce a burden of illness from communicable diseases that differs drastically from the rest of the world. Added to these problems, the health budgets are low and opportunities for community interventions very small. A demographic transition is under way throughout the world: as populations age, the burden of noncommunicable diseases (cardiovascular illnesses, stroke and cancer) increases, particularly in the least favoured regions. Thus, the majority of least-developed countries are facing a double burden from communicable and noncommunicable diseases. The global public health community is now faced with a more complex and diverse pattern of adult disease than previously expected and proposes a double response that integrates prevention and control of both communicable and noncommunicable diseases within a comprehensive health-care system (1). Some diseases that used to be found in the developed world but have virtually disappeared, such as poliomyelitis, leprosy and neurosyphilis, are still taking their toll in developing regions. In addition, some of the protozoan and helminthic infections that are so characteristic of the tropics are now being seen with increasing frequency in developed countries owing to migration, large-scale military ventures and rapid means of transport that have the undesirable potential to introduce disease vectors. Although some infectious diseases have been nearly wiped out, the vast majority of them will not be eliminated in the foreseeable future. Indeed, WHO reports that at least 30 new diseases have been scientically recognized around the world in the last 20 years (2). These emerging diseases include hantavirus (rst identied in the United States in 1993), cryptosporidiosis (a waterborne cause of diarrhoea that recently affected more than 400 000 people in a single outbreak in the United States), the Ebola virus from Africa and the human immunodeciency virus (HIV), among others. Re-emerging diseases are the infections once thought
96
VIRAL DISEASES
HIV/AIDS
The acquired immunodeciency syndrome (AIDS) is caused by a retrovirus known as the human immunodeciency virus (HIV), which attacks and impairs the bodys natural defence system against disease and infection. HIV is a slow-acting virus that may take years to produce illness in a person. During this period, an HIV-infected persons defence system is impaired, and other viruses, bacteria and parasites take advantage of this opportunity to further weaken the body and cause various illnesses, such as pneumonia, tuberculosis and mycosis. When a person starts having such opportunistic infections, he or she has AIDS. The amount of time it takes for HIV infection to become full-blown AIDS depends on the persons general health and nutritional status before and during the time of HIV infection. The average time for an adult is approximately 10 years without antiretroviral therapy (ART). Women are more likely to be infected with HIV than men. Children are also at risk (4). The number of people living with HIV globally has reached its highest level with an estimated 40.3 million people, rising from an estimated 37.5 million in 2003. More than three million people died of AIDS-related illnesses in 2005; more than 500 000 of them were children. Sub-Saharan Africa continues to be the most affected region globally, with 64% of new infections occurring there. HIV treatment has improved markedly, however, and hundreds of thousands of people are now living longer in better health because they are receiving ART: an estimated 250350 000 deaths were averted in 2005 because of expanded access to HIV treatment (5). Neurological complications occur in 3970% of patients with AIDS and signicantly impact on functional capacity, quality of life and survival. Neuropathological examination identies abnormal neurological conditions in more than 90% of autopsies but is not always demonstrated clinically (6). The main etiological considerations include primary HIV-related syndromes, opportunistic conditions, inammatory conditions, and medications (7 ) (see Table 3.5.1).
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Opportunistic conditions
Multiple investigations in recent years suggest that the effects of neurological complications and opportunistic infections related to HIV have a clear trend to diminish since the introduction of new and more powerful antiretroviral agents. Nevertheless, prolonging the life of patients infected by the virus, attributable to therapeutic success, paradoxically favours the emergence of some neurological affections as treatment-associated neuropathy/myopathy; these affections can be more important than the benets of therapy to achieve viral suppression. Accurately diagnosing neurological disease in the HIV-infected individual is crucial for several reasons. First, many complications are treatable and their treatment can lead to either increased survival or improved quality of life. Second, identifying currently untreatable conditions provides the patient with the opportunity to participate in a growing number of therapeutic trials. Further, an accurate and focused diagnostic assessment and treatment plan will limit therapeutic misadventures and lead to cost-effective care delivery. The worldwide use of highly active antiretroviral therapy (HAART) has played an important role in changing the incidence of neurological complications in AIDS patients. Recent studies have shown that HAART has produced both quantitative and qualitative changes in the pattern of HIV neuropathology: an overall decrease in the incidence of some cerebral opportunistic infections such as toxoplasmosis and cytomegalovirus encephalitis, for which successful treatment is available, whereas other uncommon types and new variants of brain infections, such as varicellazoster encephalitis, herpes simplex virus encephalitis or HIV encephalitis, are being reported more frequently as ART promotes some immune recovery and increases survival (8). In developing countries, some endemic infections such as tuberculosis and Chagas disease have re-emerged in direct association with the spreading of HIV, and are now being considered as markers of AIDS. Unfortunately, some patients may develop paradoxical clinical outcomes after starting treatment with HAART, known as neurological immune restoration inammatory syndrome (NIRIS). Some treatment-related neurological disorders, like zidovudine-induced myopathy, nucleoside analog-induced neuropathy and efavirenz-induced neuropsychiatric disorders, can be more important than the benets of the therapy of viral suppression (9). Some therapies can prevent, treat or even cure many of the opportunistic infections and relieve the symptoms associated with them, but there is no cure for HIV/AIDS. The core benet of HAART lies in its ability to reduce the rate of opportunistic infections by enhancing immune function,
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Viral encephalitis
Acute viral encephalitis is often an unusual manifestation of common viral infections and most commonly affects children and young adults. Every day, more types of viruses are being associated with encephalitis (see Box 3.5.1), and its variable presence depends on the age group, geographical zone, season of the year and the state of health of patients. In the United States, epidemiological studies calculate the incidence of viral encephalitis approximately at 3.57.4 per 100 000 population. Estimates have been given for some causes of viral encephalitis: for example, it has been estimated that herpes simplex encephalitis (HSE) has an annual incidence of about one per million. Herpes simplex encephalitis is the most important and common cause of fatal sporadic viral encephalitis in the industrialized world. At a global level, it seems that the most common cause of epidemic encephalitis is actually Japanese B encephalitis, with 1015 000 deaths per year, markedly more than for herpes simplex encephalitis. It must be considered, however, that in up to about 50% of cases of viral encephalitis no specic cause can be found, so the predominant type is difcult to determine (11).
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Poliomyelitis
Poliomyelitis is a crippling disease caused by any one of three related viruses, poliovirus types 1, 2 or 3. The primary way to spread poliovirus is through the faecaloral route: the virus enters the body through the mouth when people eat food or drink water that is contaminated with faeces. The virus then multiplies in the intestine, enters the bloodstream, and may invade certain types of nerve cells which it can damage or destroy. Polioviruses spread very easily in areas with poor hygiene. In any child under 15 years of age with acute accid paralysis or any person of any age with paralytic illness, poliomyelitis always has to be suspected. In 1963, Cuba began using an oral vaccine in a series of nationwide polio campaigns. Shortly thereafter, indigenous wild poliovirus transmission was interrupted. Through an extraordinary international effort that begun 18 years ago, indigenous polioviruses have now been eliminated from all but four countries of the world, down from over 125 when the collaboration started (13). This progress is the result of a unique partnership forged between governments and the spearheading partners of the Global Polio Eradication Initiative WHO, Rotary International, the United States Centers for Disease Control and Prevention (CDC) and UNICEF to take up key challenges to reach all children, everywhere. The most visible element of the polio eradication initiative has been the National Immunization Days, as they require the immunization of every child under ve years of age (nearly 20% of a countrys population) several times a year for a number of years in a row. As the result of an aggressive, deliberate and internationally coordinated effort, endemic
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Rabies
Rabies is one of the oldest and most feared diseases reported in medical literature. Rabies is a viral zoonosis (an animal disease transmissible to humans) caused by rhabdoviruses of the genus Lyssavirus. The disease is maintained in nature by several domestic and wild animal reservoir species, including dogs, foxes, mongooses, raccoons, skunks and many species of bat. Human infection is incidental to the epidemiology of rabies. In terms of risks to human health, dogs are the most dangerous reservoir: more than 99.9 % of human deaths from rabies worldwide result from the bite of a rabid dog. It is estimated that 50 000 persons die of rabies each year, mainly in Africa and Asia. Human infection occurs when the virus, contained in the saliva of a rabid animal, is transmitted through penetrating bite wounds, open cuts in the skin, or contact with mucous membranes. The severity of the bite determines the risk of infection. The virus slowly travels up the nerve to reach the CNS where it replicates and then travels down nerves to the salivary glands where there is further replication. Man is occasionally infected, and once infection is established in the CNS the outcome is almost invariably fatal. Second-generation vaccines consisting of highly puried vaccines prepared on primary and continuous cell lines and in embryonating eggs are available, though expensive, to prevent the occurrence of the disease in persons exposed to an animal suspected of rabies. The vaccines are usually administered according to regimens involving fewer doses (usually ve or six) than those used for brain tissue vaccines. The regimens most commonly applied in the world are those recommended by WHO. Control of rabies depends on education, vaccination of dogs, cats and farm animals and notication of suspected cases to local authorities (14).
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Leprosy neuropathy
Leprosy is the cause of the most common treatable neuropathy in the world, caused by Mycobacterium leprae. The incubation period of the disease is about ve years: symptoms, however, can take as long as 20 years to appear. The infection could affect nerves by direct invasion or during immunological reactions. In rare instances, the diagnosis can be missed, because leprosy neuropathy may present without skin lesions (neuritic form of leprosy). Patients with this form of disease display only signs and symptoms of sensory impairment and muscle weakness, posing difculties for diagnosis, particularly in services where diagnostic facilities such as bacilloscopy, electroneuromyography and nerve biopsy are not available. Delay in treatment is a major problem, because the disease usually progresses and the resulting disability if untreated may be severe, even though mycobacteria may be eliminated. Delay in treatment is, however, usually a result of delayed presentation because of the associated stigma. People with long-term leprosy may lose the use of their hands or feet because of repeated injury resulting from lack of sensation. Early diagnosis and treatment with the WHO-recommended multidrug therapy (MDT) is essential in order to prevent the disease from progressing and resulting in disability.
Bacterial meningitis
Bacterial meningitis is a very common cause of morbidity, mortality and neurological complications in both children and adults, especially in children. It has an annual incidence of 46
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Tetanus
Tetanus is acquired through exposure to the spores of the bacterium Clostridium tetani which are universally present in the soil. The disease is caused by the action of a potent neurotoxin produced during the growth of the bacteria in dead tissues, e.g. dirty wounds or for neonatal tetanus in the umbilicus following non-sterile delivery. Tetanus is not transmitted from person to person: infection usually occurs when dirt enters a wound or cut. At the end of the 1980s, neonatal tetanus was considered a major public health problem. WHO estimated that, in 1988, 787 000 newborn children died of neonatal tetanus, a rate of 6.5 cases per 1000 live births. In 2004 the number of reported cases was 13 448. A worldwide total of 213 000 deaths were estimated to have occurred in 2002, 198 000 of them concerning children younger than ve years of age (23). Unlike poliomyelitis and smallpox, the disease cannot be eradicated because tetanus spores are present in the environment. Once infection occurs, mortality rates are extremely high, especially in areas where appropriate medical care is not available. However, this death toll can be prevented. Neonatal tetanus can be prevented by immunizing pregnant women and improving the hygienic conditions of delivery. Adult tetanus can be prevented by immunizing people at risk, such as workers manipulating soil; others at risk of cuts should be also included in the prevention measures. Some forms of toxoid are available (DTP, DT, TT or Td) and at least three primary doses should be given by the intramuscular route. Vaccination coverage with three doses of DTP is more than 80% for most countries around the world. The Maternal and Neonatal Tetanus elimination initiative was
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PARASITIC DISEASES
Neurocysticercosis
Cysticercosis is infection by the larvae of the pork tapeworm Taenia solium. The adult tapeworm (at, ribbon-like, approximately 24 m long) lives only in the small intestine of humans, who acquire it (taeniasis) by eating undercooked pork containing the viable larvae or cysticerci. A tapeworm carrier passes microscopic Taenia eggs with the faeces, contaminating the close environment and contacts and causing cysticercosis to pigs and humans. Human beings therefore acquire cysticercosis through faecaloral contamination with T. solium eggs (24). Thus, vegetarians and other people who do not eat pork can acquire cysticercosis. Recent epidemiological evidence suggests that the most common source of infective eggs is a symptom-free tapeworm carrier in the household. Therefore, cysticercosis should be seen as a disease mostly transmitted from person to person (25). In the CNS, the larvae or cysticerci can cause epilepsy, hydrocephalus, spinal cord involvement, stroke, etc. (24, 26). Cysticercosis is the parasitic disease that most frequently affects the CNS and is one of the major health problems of developing countries in Africa, Asia and Latin America. In addition, because of high immigration rates from endemic to non-endemic areas and tourism, neurocysticercosis is now commonly seen in countries that were previously free of the disease. Despite the advances in diagnosis and therapy, neurocysticercosis remains endemic in most low income countries, where it represents one of the most common causes of acquired epilepsy (27 ). Almost 50 000 deaths attributable to neurocysticercosis occur every year. Many more patients survive but are left with irreversible brain damage with all the social and economic consequences that this implies (28). Seizures occur in up to 70% of patients. Several articles from different countries in Latin America consistently showed an association between around 30% of all seizures and cysticercosis (29). Accurate diagnosis of neurocysticercosis is based on assessment of the clinical and epidemiological data and the results of neuroimaging studies and immunological tests (30). Therapy must be individualized according to the location of parasites and the degree of disease activity: this implies symptomatic therapy, anticysticidal drugs (albendazole/praziquantel), antiepileptic drugs and surgical treatment of complications such as hydrocephalus. Neurocysticercosis is one of a few conditions included in a list of potentially eradicable infectious diseases of public health importance (31). The control strategy that seems promising at the moment is a combination of different available tools in order to interrupt or reduce the cycle of direct person-to-person transmission: mass human chemotherapy to eliminate the tapeworm stage, enforced meat inspection and control, improvement of pig husbandry and inspection, treatment of infected animals, surveillance, identication and treatment of individuals who are direct sources of contagion (human carriers of adult tapeworm) and their close contacts, combined with hygiene education and better sanitation. Animal vaccines are under development. Major obstacles include the lack of basic sanitary facilities in endemic areas, the extent of domestic pig-rearing, the costs of the interventions, and their cultural acceptability. Multiple genotypes of T. solium ramications have been discovered in different regions, which could explain some of the possible differences in pathology of T. solium worldwide. Recently, a proposal was published to declare neurocysticercosis an international reportable disease (32). WHO suggests that all endemic countries should recognize the importance of taeniasis and cysticercosis, collect epidemiological data and adopt policies and strategies for their control. So far, the infection has not been eliminated from any
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Cerebral malaria
Malaria remains a serious public health problem in the tropics, mostly in Africa. There exist four Plasmodium species that affect humans; of these, only Plasmodium falciparum can sequester in capillaries of the CNS and cause cerebral malaria. The infection is acquired when the parasite is inoculated through the skin during the sting of an infected Anopheles mosquito. Some patients with cerebral malaria present with diffuse cerebral oedema, small haemorrhages and occlusion of cerebral vessels by parasitized red cells. The burden of falciparum malaria is not only because of infection and mortality: the neurocognitive sequelae add signicantly to this burden (33). P. falciparum is identied by examination of blood smears with Giemsa stain. Since parasitaemia is cyclical, repeated examinations may be required. The CSF is normal in cerebral malaria. Neuroimaging studies may demonstrate brain swelling, cerebral infarcts, or small haemorrhages in severe cases. Artemisinin derivatives and quinine are the drugs of choice for cerebral malaria. Despite therapy, mortality remains high in severe or complicated malaria (34). Preventive strategies relied upon are: the early treatment of malaria infections with effective medicines (artemisinin-based combination therapies) to prevent the progression of the disease to severe malaria; and vector control through different practices to reduce the rate of infection (use of insecticide-treated nets, bednets, insecticide sprays and mosquito coils). All these methods have been found to be highly cost effective. At present, multiple studies are under way to modify Plasmodium genes in order to diminish parasite virulence and consequently the morbidity and mortality attributable to malaria.
Toxoplasmosis
Toxoplasmosis is a disease caused by an obligate intracellular protozoal parasite termed Toxoplasma gondii. Human infection usually occurs via the oral or transplacental route. Consumption of raw or undercooked meat containing viable tissue cysts (principally lamb and pork) and direct ingestion of infective oocysts in other foods (including vegetables contaminated by feline faeces) are common sources of infection. Transplacental infection may occur if the mother acquires an acute infection or if a latent infection is reactivated during immunosuppression. In immunocompetent women a primary infection during early pregnancy may lead to fetal infection, with death of the fetus or severe postnatal manifestations. Later in pregnancy, maternal infection results in mild or subclinical fetal disease. In adults, most T. gondii infections are subclinical, but severe infection can occur in patients who are immunocompromised, such as those with AIDS and malignancies. Affected organs include both the grey and white matter of the brain, retina, alveolar lining of the lungs, heart, and skeletal muscle. Patients with AIDS are at particular risk for developing disseminated toxoplasmosis, which more often manifests as CNS abnormalities. As many as 50% of patients with AIDS who are seropositive for T. gondii develop encephalitis. Toxoplasmosis is the most common cause of a focal brain lesion in patients with AIDS. The disease commonly localizes to the basal ganglia, though other sites in the brain and spinal cord may be affected. A solitary focus may be seen in one third of patients, but multiple foci are more common. In AIDS-related Toxoplasma encephalitis, a well-circumscribed indolent granulomatous process or features of diffuse necrotizing encephalitis occur. For most people, prevention of toxoplasmosis is not a serious concern, as infection generally causes no symptoms or mild symptoms. High-risk groups, however, should consider being tested for Toxoplasma infection. HIV-infected individuals who test positive should receive drugs to prevent
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Schistosomiasis
Schistosomiasis is an infection with a relatively low mortality rate but a high morbidity rate; it is endemic in 74 developing countries, with more than 80% of infected people living in sub-Saharan Africa. Infection is caused by trematode atworms (ukes) of the genus Schistosoma: in freshwater, intermediate snail hosts release infective forms of the parasite. There are ve species of schistosomes able to infect humans: Schistosoma haematobium (the urinary form) and S. japonicum, S. mekongi, S. mansoni and S. intercalatum (the intestinal forms). If people are in contact with water where infected snails live, they become infected when larval forms of the parasites penetrate their skin. Later, adult male and female schistosomes pair and live together in human blood vessels. The females release eggs, some of which are passed out in the urine (in S. haematobium infection) or stools (S. mansoni and S. japonicum), but some eggs are trapped in body tissues. Immune reactions to eggs lodged in tissues are the cause of disease. Systemic complications are bladder cancer, progressive enlargement of the liver and spleen, intestinal damage due to brotic lesions around eggs lodged in these tissues, and hypertension of the abdominal blood vessels. Most cases of cerebral schistosomiasis are observed with S. japonicum, constituting 24% of all S. japonicum infections. However, CNS schistosomiasis also can occur with other species and involves seizures, headache, back pain, bladder dysfunction, paresthesias and lower limb weakness. Death is most often caused by bladder cancer associated with urinary schistosomiasis and by bleeding from varicose veins in the oesophagus associated with intestinal schistosomiasis. Children are especially vulnerable to infection, which develops into chronic disease if not treated. Diagnosis is made by using urine ltration and faecal smear techniques, antigen detection in endemic areas and antibody tests in non-endemic areas. The disease is controlled through an integrated approach: drug treatment with praziquantel or oxamniquine (effective only against S. mansoni), provision of an adequate safe water supply, sanitation and health education (39).
Hydatidosis
Cystic hydatidosis/echinococcosis is an important zoonosis caused by the tapeworm Echinococcus granulosus. At present, four species of Echinococcus are recognized: E. granulosus, E. multilocularis, E. oligarthrus and E. vogeli. The parasite is distributed worldwide and about 23 million patients are estimated in the world (40). It causes serious human suffering and considerable losses in agricultural and human productivity. General lack of awareness of transmission factors and prevention measures among the population at risk, abundance of stray dogs, poor meat inspection in abattoirs, improper disposal of offal and home slaughtering practices play a role in the persistence of the disease. The incidence of surgical cases ranges from 0.1 to 45 cases per 100 000 people. The real prevalence ranges between 0.22% and 24% in endemic areas. Ultrasounds have been very useful in large-scale prevalence surveys. Large prevalence studies have been conducted in many countries: in the Libyan Arab Jamahiriya, Morocco and Tunisia, the prevalence ranged from 1% to 2%. In the normal life-cycle of Echinococcus species, adult tapeworms (36 mm long) inhabit the small intestine of carnivorous denitive hosts, such as dogs, coyotes or wolves, and echinococcal cyst stages occur in herbivorous intermediate hosts, such as sheep, cattle and goats. In most infected countries there is a dogsheep cycle in which grazing sheep ingest tapeworm eggs passed in the faeces of an infected dog. Dogs ingest infected sheep viscera, mainly liver and lungs,
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REFERENCES
1. The world health report 2003 Shaping the future. Geneva, World Health Organization, 2003. 2. The world health report 1996 Fighting disease, fostering development. Geneva, World Health Organization, 1996. 3. Atlas: Country resources for neurological disorders 2004. Geneva, World Health Organization, 2004. 4. HIV/AIDS: a guide for nutrition, care and support. Geneva, United Nations Joint Programme on HIV/AIDS and World Health Organization, 2001. 5. AIDS epidemic update 2005. Geneva, Joint United Nations Programme on HIV/AIDS and World Health Organization, 2005. 6. Budka H. Neuropathology of human immunodeciency virus infection. Brain Pathology, 1991, 1:163175. 7. Bacellar H et al. Temporal trends in the incidence of HIV-1-related neurologic diseases: Multicenter AIDS Cohort Study, 19851992. Neurology, 1994, 44:18921900. 8. Gray F et al. The changing pattern of HIV neuropathology in the HAART era. Journal of Neuropathology and Experimental Neurology, 2003, 62:429440. 9. Treisman G, Kaplin A. Neurologic and psychiatric complications of antiretroviral agents. AIDS, 2002, 16:12011215. 10. Jordan-Harder B et al. Thirteen years HIV-1 sentinel surveillance and indicators for behavioural change suggest impact of programme activities in south-west Tanzania. AIDS, 2004, 18:287294. 11. Kennedy PGE. Viral encephalitis: causes, differential diagnosis and management. Journal of Neurology, Neurosurgery and Psychiatry, 2004, 75(Suppl. I):1015. 12. Lopez W. West Nile virus in New York City. American Journal of Public Health, 2002, 92:12181221. 13. Global eradication of poliomyelitis by the year 2000. Geneva, World Health Organization, 1988 (World Health Assembly resolution WHA41.28). 14. Centers for Disease Control and Prevention. Human rabies Montana and Washington, 1997. Morbidity and Mortality Weekly Report, 1997, 46:770774. 15. Global tuberculosis control: surveillance, planning and nancing. Geneva, World Health Organization, 2006 (WHO/HTM/TB/2006.362). 16. The Stop TB strategy. Geneva, World Health Organization, 2006 (WHO/HTM/TB/2006.368). 17. Kox LFF, Kuijper S, Kolk AHJ. Early diagnosis of tuberculous meningitis by polymerase chain reaction. Neurology, 1995, 45:22282232. 18. Bourdin Trunz B, Fine PEM, Dye C. Effect of BCG vaccination on childhood tuberculous meningitis and miliary tuberculosis worldwide: a meta-analysis and assessment of cost-effectiveness. Lancet, 2006, 367:1175 1182. 19. International standards for tuberculosis care. The Hague, Tuberculosis Coalition for Technical Assistance, 2006. 20. Van de Beek D et al. Community-acquired bacterial meningitis in adults. New England Journal of Medicine, 2006, 354:4453. 21. Wright JP, Ford HL. Bacterial meningitis in developing countries. Tropical Doctor, 1995, 25:58. 22. Van de Beek D et al. Steroids in adults with bacterial meningitis: a systematic review. Lancet Infectious Diseases, 2004, 4:139143. 23. The world health report 2005 Make every mother and child count. Geneva, World Health Organization, 2005. 24. Sanchez AL et al. A population based, case-control study of Taenia solium taeniasis and cysticercosis. Annals of Tropical Medicine and Parasitology, 1999, 93:247258. 25. Garca HH et al. The Cysticercosis Working Group in Peru. Taenia solium cysticercosis. Lancet, 2003, 362:547556. 26. Rodriguez-Salinas L, Medina MT. Stroke in developing countries. In: Bogousslavsky J et al., eds. Stroke: selected topics. New York, World Federation of Neurology and Demos Medical Publishing, 2006:4962 (Seminars in Clinical Neurology, in press). 27. Medina MT et al. Neurocysticercosis as the main cause of late-onset epilepsy in Mexico. Archives of Internal Medicine, 1990, 150:325327. 28. Gemmel M et al. Guidelines for surveillance, prevention and control of taeniasis/cysticercosis. Geneva, World Health Organization, 1983 (WHO/VPH/83.49). 29. Montano SM et al, The Cysticercosis Working Group in Peru. Neurocysticercosis: association between seizures, serology and brain CT in rural Peru. Neurology, 2005, 65:229233. 30. Del Brutto OH et al. Proposed diagnostic criteria for neurocysticercosis. Neurology, 2001, 57:177183. 31. Centers for Disease Control and Prevention. Recommendations of the International Task Force for Disease Eradication. Morbidity and Mortality Weekly Report, 1993, 42:138.
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RECOMMENDED READING
Craig PS, Rogan MT, Allan JC. Detection, screening and community epidemiology of taeniid cestode zoonoses: cystic echinococcosis, alveolar echinococcosis and neurocysticercosis. Advances in Parasitology, 1996, 38:169250. Eckert MA et al., eds. Manual on echinococcosis in humans and animals: a public health problem of global concern. Paris, World Health Organization and Ofce International des Epizooties, 2001. Garca HH, Del Brutto OH. The Cysticercosis Working Group in Peru. Neurocysticercosis: updated concepts about an old disease. Lancet Neurology, 2005, 4:653661. Garca HH, Gonzalez AE, Gilman RH. The Cysticercosis Working Group in Peru. Diagnosis, treatment and control of Taenia solium cysticercosis. Current Opinion in Infectious Diseases, 2003, 16:411419. Gendelman HE, Persidsky Y. Infections of the nervous system. Lancet Neurology, 2005, 4:1213. Medina MT, DeGiorgio C. Introduction to neurocysticercosis: a worldwide epidemic. Neurosurgery Focus, 2002, 12:6 (http://www.neurosurg.focus.org/jun02/12-6-nsf-toc.html). Medina MT et al. Prevalence, incidence, and etiology of epilepsies in rural Honduras: the Salama study. Epilepsia, 2005, 46:124131. Raviglione MC, Snider DE, Kochi A. Global epidemiology of tuberculosis: morbidity and mortality of a worldwide epidemic. JAMA, 1995, 273:220. Romn G. Cerebral malaria: the unsolved riddle. Journal of the Neurological Sciences, 1991, 101:16. Romn G et al. A proposal to declare neurocysticercosis an international reportable disease. Bulletin of the World Health Organization, 2000, 78:399406. Shakir B, Newman P, Poser CH. Tropical neurology. London, WB Saunders Company, 1996. Uplekar MW, Antia NH. Clinical and histopathological observations on pure neuritic leprosy. Indian Journal of Leprosy, 1986, 58:513521. AIDS epidemic update 2005. Geneva, Joint United Nations Programme on HIV/AIDS and World Health Organization, 2005. Atlas: Country resources for neurological disorders 2004. Geneva, World Health Organization (2004). The Stop TB strategy. Geneva, World Health Organization, 2006 (WHO/HTM/TB/2006.368).
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In low income countries, inadequate amounts of food (causing conditions such as child malnutrition and retarded growth) and 121 Prevention of nutritional deciencies inadequate diversity of food (causing deciency of vital micronu123 A public health framework trients such as vitamins, minerals or trace elements) continue to 124 Conclusions and recommendations be priority health problems. Malnutrition in all its forms increases the risk of disease and early death. Nearly 800 million people in the world do not have enough to eat. Malnutrition affects all age groups, but it is especially common among poor people and those with inadequate access to health education, clean water and good sanitation. Most of the malnutrition-related neurological disorders are preventable.
118 Toxiconutritional disorders
Chronic food decits affect about 792 million people in the world (1). Malnutrition directly or indirectly affects a variety of organ systems including the central nervous system (CNS). A number of nutritional conditions are included in the Global Burden of Disease (GBD) study, such as proteinenergy malnutrition, iodine deciency, vitamin A deciency, and iron deciency anaemia. Over 15% of the disabilityadjusted life years (DALYs) lost globally are estimated to be from malnutrition (2). This section focuses on neurological disorders associated with malnutrition. In addition, it touches briey on the ingestion of toxic substances in food or alcohol, as these also contribute to neurological disorders. Most of the malnutrition-related neurological disorders can be prevented and therefore they are of public health concern. Raising awareness in the population, among leaders and decision-makers and in the international community is important in order to adopt an appropriate health policy.
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RDAa
In childhood: long-term mental decit Beri-beri, polyneuropathy, Wernickes encephalopathy Pellagra including dementia and depression Polyneuropathy Progressive myelopathy with sensory disturbances in the legs Neural tube defects (myelomeningocele) of the fetus, cognitive dysfunction in children and elderly? Iodine deciency disorders Delayed mental development in children Delayed motor development in children, depression Adverse mood states
150 g 15 mg 12 mg 55 mg
Table 3.6.2 Potentially toxic food compounds that may contribute to neurological disorders
Food compound Alcohol Lathyrus sativus Cyanogenic glucosides from insufciently processed cassava roots Potential neurological disorder when ingested Fetal alcohol syndrome, retarded mental development in childhood, Wernickes encephalopathy, visual problems (amblyopia), peripheral neuropathy Spastic paraparesis (lathyrism) Konzo, tropic ataxic neuropathy
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Micronutrient deciencies
Micronutrients is the term used for those essential nutrients that are needed in small amounts for human growth and functioning. They are essentially used as cofactors for enzymes engaged in various biochemical reactions. They comprise vitamins, fat-soluble as well as water-soluble, and trace elements (= minerals). Iron, vitamin A, zinc and iodine are most discussed today, but other important micronutrients are vitamin C and the vitamin B complex. Diets that supply adequate energy and have an acceptable nutrient density will usually also cover the needs for micronutrients. When the diet is otherwise monotonous, however, it is recommended to supplement it with micronutrient-rich foods. Food preservation methods, high temperature and exposure to sunlight can reduce the activity of many vitamins. Most of these deciencies are strongly linked to poverty and human deprivation. Some of these conditions are much more signicant with regard to their global occurrence and their impact on the nervous system than other micronutrient deciencies, so this section focuses on deciencies of vitamin A, vitamin B complex, iodine and iron.
Vitamin A deciency
Vitamin A assumes two types of function in the body: systemic functions (in the whole body) and local functions in the eye. Vitamin A is very important for the mucous membranes as it is needed for the proper production of mucopolysaccharides, which help to protect against infections. If vitamin A is decient, the wetness of the mucous membranes will decrease and the membranes will become more like skin than mucous membranes. This can be seen in the eye as xerophthalmia (dry eye in Greek). Inside the eye, vitamin A is used in the rods (the receptors for low intensities of light). If there is too little vitamin A, the person will not be able to see in low light intensity: he or she will become nightblind. Vitamin A deciency has long been identied as the major cause of nutritional blindness. This is still an important problem around the world: it is estimated that 250500 000 children are blinded each year because of eye damage brought about by severe vitamin A deciency. It is the single most important cause of blindness in low and middle income countries.
Figure 3.6.1 Mean developmental quotients of stunteda and non-stuntedb children: results of intervention over two years
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Stunted
18
95
Controls
a Adjusted for initial age and score. b Adjusted for age only. Source: (6).
90 Enrolment 8
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At the World Summit for Children in 1990, the problem of iodine deciency disorders was highlighted and a strong political will to eliminate them was demonstrated. At that time, the scale and severity of the iodine problem was only just being realized. Since then, several surveys have shown even more severe damage than was estimated from this deciency in many regions of the world. Work to eliminate iodine deciency disorders has made enormous progress and is becoming a success story in the prevention of a nutritional deciency. WHO has issued a useful guide to help programme managers assess the problem and monitor progress towards its elimination (20). The main intervention strategy for control of iodine deciency disorders is universal salt iodization. Salt was chosen as the commodity to be fortied for a number of reasons: it is widely consumed in fairly equal amounts by most people in a population, it is usually produced centrally or in a few factories, and the cost of iodizing is low (about US$ 0.05 per person per year). Over the last decade, extraordinary progress has been made in increasing the number of people consuming iodized salt. In 1998, more than 90 countries had salt iodization programmes. Now, more than two thirds of households living in countries affected by iodine deciency disorders consume iodized salt. Universal salt iodization ranges from 6390% in Africa, the Americas, South-East Asia and the Western Pacic, whereas in Europe it is only 27%, thus leaving Europeans at risk of iodine deciency disorders. Because of active programmes of salt fortication, iodine deciency disorders are rapidly declining in the world. In 1990, 40 million children were born with mental impairment attributable to iodine deciency and 120 000 cretins were born, which was substantially more than just seven years later. WHO has estimated that the number of people with goitre will decrease to 350 million by the year 2025 as a result of iodine enrichment and supplementation programmes. A challenge is to enforce the legislation that has been passed in all but seven of the countries of the world with a recognized iodine-deciency public health problem. All the salt producers, from large industries to small-scale producers, need to be encouraged to use the more expensive procedure to fortify their salt production, and the consumers also need to be informed. Quality control and monitoring of the impact of the procedures are other continuing tasks related to the worlds most widespread preventable cause of mental impairment (20).
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Zinc deciency
There is a close connection between zinc deciency and stunting. In addition, zinc supplementation of young children in low income countries improves their neurophysiological performance (26), also in combination with iron supplements (27 ). Some behavioural abnormalities in adults also seem to respond favourably to zinc supplementation, such as mood changes, emotional lability, anorexia, irritability and depression (28).
Selenium deciency
Selenium deciency has been linked to adverse mood states (29). Selenium supplementation together with other vitamins has been found benecial in the treatment of mood lability (30). Generally, the scientic information about selenium and neurological disorders remains scarce.
TOXICONUTRITIONAL DISORDERS
In the 19th century, medical science successfully revealed the causation of several neurological disorders that occurred in localized epidemics or endemic foci. There are, however, still a number of obscure neurological disorders occurring in localized epidemics or endemic foci in tropical countries. Most of these syndromes consist of various combinations of peripheral polyneuropathy and signs of spinal cord involvement. The term tropical myeloneuropathies has been used to group these disorders of unknown etiology; to reduce the confused clinical terminology, Romn distinguishes two clinical groups which he calls tropical ataxic neuropathy, with prominent sensory
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(GDP) attributable
1.3 1.1
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Wernickes encephalopathy
Wernickes encephalopathy is the acute consequence of a vitamin B1 deciency in people with severe alcohol abuse. It is due to very poor diet, intestinal malabsorption and loss of liver thiamine stores. The onset may coincide with an abstinence period and is generally marked by somnolence and mental confusion; which gradually worsens, together with cerebellar signs, hypertonia, paralysis and/or ocular signs. The prognosis depends on how quickly the patient is given high-dose vitamin B1 (by intravenous route, preferably). A delay or an absence of treatment increases the risk of psychiatric sequelae (memory disorders and/or intellectual deterioration). If the treatment is too late, the consequences could be an evolution to a WernickeKorsakoff syndrome, a dementia.
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REFERENCES
1. The state of food insecurity in the world 2000. Rome, Food and Agriculture Organization of the United Nations, 2000. 2. Ezzati M et al. Selected major risk factors and global and regional burden of disease. Lancet, 2002, 360:13471360. 3. Onis M de et al. The worldwide magnitude of proteinenergy malnutrition: an overview from the WHO Global Database on Child Growth. Bulletin of the World Health Organization, 1993, 71:703712. 4. Grantham-McGregor S, Ani C. Cognition and undernutrition: evidence for vulnerable period. Forum of Nutrition, 2003, 56:272275. 5. Grantham-McGregor S, Baker-Henningham H. Review of the evidence linking protein and energy to mental development. Public Health Nutrition, 2005, 8:11911201. 6. Grantham-McGregor SM et al. Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaican study. Lancet, 1991, 338:15. 7. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva, World Health Organization, 1999 (http://www.who.int/nut). 8. McCarthy M. Cuban neuropathy. Lancet, 1994, 343:844. 9. Ordunez-Garcia PO et al. Cuban epidemic neuropathy, 1991 to 1994: history repeats itself a century after the amblyopia of the blockade. American Journal of Public Health, 1996, 86:738743. 10. Neumann CG et al. Biochemical evidence of thiamin deciency in young Ghanaian children. American Journal of Clinical Nutrition, 1979, 32:99104. 11. Malouf R, Grimley Evans J. The effect of vitamin B6 on cognition. Cochrane Database of Systematic Reviews, 2003, 4:CD004393. 12. Thaver D et al. Pyridoxine (vitamin B6) supplementation in pregnancy. Cochrane Database of Systematic Reviews, 2006, 2:CD000179. 13. Lumley J et al. Periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects. Cochrane Database of Systematic Reviews, 2001, 3:CD001056. 14. Oakley GP Jr et al. Recommendations for accelerating global action to prevent folic acid-preventable birth defects and other folate-deciency diseases: meeting of experts on preventing folic acid-preventable neural tube defects. Birth Defects Research. Part A, Clinical and Molecular Teratology, 2004, 70:835837. 15. Oakley GP Jr et al. Scientic evidence supporting folic acid fortication of our in Australia and New Zealand. Birth Defects Research. Part A, Clinical and Molecular Teratology, 2004, 70:838841. 16. Dietrich M et al. The effect of folate fortication of cereal-grain products on blood folate status, dietary folate intake, and dietary folate sources among adult non-supplement users in the United States. Journal of the American College of Nutrition, 2005, 24:266274. 17. Eichholzer M, Tonz O, Zimmerman R. Folic acid: a public health challenge. Lancet, 2006, 367:13521361. 18. Malouf R, Areosa Sastre A. Vitamin B12 for cognition. Cochrane Database of Systematic Reviews, 2003, 3: CD004326. 19. The state of the worlds children. New York, United Nations Childrens Fund, 1995. 20. Assessment of iodine deciency disorders and monitoring their elimination. A guide for programme managers. Geneva, World Health Organization, 2001. 21. Andraca I de et al. Psychomotor development and behavior in iron-decient anemic infants. Nutrition Reviews, 1997, 55:125132. 22. Lozoff B, Wachs T. Functional correlates of nutritional anemias in infancy and childhood child development and behavior. In: Ramakrishnan U, ed. Nutritional anemias. Boca Raton, FL, CRC Press, 2001:6988. 23. Hunt JM. Reversing productivity losses from iron deciency: the economic case. Journal of Nutrition, 2002, 132(Suppl. 4):794S801S. 24. Horton S. Opportunities for investment in nutrition in low-income Asia. Asian Development Review, 1999, 17:246273. 25. WHO Global Malaria Programme. Geneva, World Health Organization (http://malaria.who.int/). 26. Bentley ME et al. Zinc supplementation affects the activity patterns of rural Guatemalan infants. Journal of Nutrition, 1997, 127:13331338. 27. Black MM et al. Iron and zinc supplementation promote motor development and exploratory behavior among Bangladeshi infants. American Journal of Clinical Nutrition, 2004, 80:903910. 28. Aggett P. Severe zinc deciency. In: Mills C, ed. Zinc in human biology. London, Springer, 1989:259280. 29. Rayman MP. The importance of selenium to human health. Lancet, 2000, 356:233241. 30. Reilly C. The nutritional trace metals. Oxford, Blackwell Publishing, 2004. 31. Romn GC et al. Tropical myeloneuropathies: the hidden endemias. Neurology, 1985, 35:11581170. 32. Fisher C. Residual neuropathological changes in Canadians held prisoners of war by the Japanese (Strachans disease). Canadian Services Medical Journal, 1955, 11:157199.
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Reilly C. The nutritional trace metals. Oxford, Blackwell Publishing, 2004. Assessment of iodine deciency disorders and monitoring their elimination. A guide for programme managers. Geneva, World Health Organization, 2001. Physical status: the use and interpretation of anthropometry. Geneva, World Health Organization, 1995. The Micronutrient Initiative web site (http://www.micronutrient.org/) includes links to the most important Internet sites regarding the individual micronutrients discussed in this chapter.
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Pain can be a direct or an indirect consequence of a neurological disorder, with physical and psychological Treatment and care dimensions that are both essential for its correct diagResearch nosis and treatment. Pain acute and chronic is a Training major public health problem that poses signicant challenges to health professionals involved in its treatment. Conclusions and recommendations Chronic pain may persist long after initial tissue damage has healed: in such cases, it becomes a specic health-care problem and a recognized disease. Adequate pain treatment is a human right, and it is the duty of any health-care system to provide it.
The current and most widely used denition of pain was published by the International Association for the Study of Pain (IASP) in 1979, which states that pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or, is described in terms of such damage (1). This denition was qualied by the Taxonomy Task Force of the association in 1994 (2): Pain is always subjective. Each individual learns the applications of the word through experiences relating to injuries in early life. The physiological effect of pain is to warn of tissue damage and so to protect life. Pain is classied as nociceptive if it is caused by the activation of nociceptors (primary sensory neurons for pain). Nociceptive pain can be somatic (pain originating from the skin or musculoskeletal system) or visceral (pain originating from visceral organs). The sensory system itself can be damaged and become the source of continuous pain. This type of pain is classied as neuropathic. Chronic neuropathic pain has no physical protective role as it continues without obvious ongoing tissue damage. Pain without any recognizable tissue or nerve damage has its cause classied as idiopathic pain. Any individual pain state may be a combination of different pains. A clinicians duty is to diagnose, treat and support pain patients, which means the identication of pain type(s) and their causative disease(s). It is also to provide adequate treatment aimed at the cause of the pain and symptomatic relief which should include psychosocial support. As the denition of pain reveals, pain has both a physical and a psychological element. The latter plays an important part in chronic pain disorders and their management. Adequate pain treatment is a human right and organization of it involving all its dimensions is the ethical and legal duty of society, health-care professionals and health-care policy-makers.
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ASSESSMENT OF PAIN
Pain has physical and psychological dimensions, both of which may be measured; they form an important aspect of the diagnosis of painful disorders and are essential for the correct application of treatment and its assessment. Pain is a subjective experience but physiological changes that accompany it may be measured: they include changes in heart rate, muscle tension, skin conductivity and electrical and metabolic activity in the brain. These measures are most consistent in acute rather than chronic pain and they are used primarily in laboratory studies. Clinically, pain assessment includes a full history of the development, nature, intensity, location and duration of pain. In addition to clinical examination, self-report measures of pain are often used. The use of words as descriptors of pain have permitted the development of graded descriptions of pain severity. For example, mild pain, moderate pain, severe pain and very severe pain, to which numerical values may be attached (14), may be graded on a numerical scale from 0 to 4 indicating the level of pain being experienced. In clinical practice, however, there is widespread use of a 010 scale, a visual analogue scale, which is easy to understand and use and is not affected by differences in language. Such measures are often repeated at intervals to gain information about the levels of pain throughout the day, after a given procedure or as a consequence of treatment. More sophisticated verbal measures use groups of words to describe the three dimensions of pain, namely its sensory component, the mood-related dimension and its evaluative aspect. This technique was devised by Melzack and others and is best seen in the Short-Form McGill Pain Questionnaire (5). The questionnaire requires the patient to be well acquainted with the words used. Often because of age, not having English as a rst language or as a result of some form of mental impairment, the scale cannot be used. In its place it is possible to use a faces scale in which recognizable facial images representing a range of pain experiences from no pain to very severe pain are readily understood. Such scales are often used with children. In the case of patients with pain generated as a result of a lesion within the nervous system (neuropathic pain) specic measures have been devised to distinguish between that type of pain and pain arising outside the nervous system (6). In the assessment of a patient with neuropathic pain, the evaluation of sensory function is crucial and can be carried out at the bedside with simple equipment. Another technique used in clinical assessment includes pain drawings, which allow the patient to mark the location of pain and its qualities using a code on a diagram of the body. A pain diary is used by patients to record levels of pain throughout the day, using a visual analogue scale. This reveals the pattern of pain severity in relation to drug therapy and activity levels. Finally, pain behaviour is
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Politicoeconomic barriers
The availability of drugs for the treatment of pain is a problem in over 150 countries. Frequently, pain management has a low priority, because the chief focus of attention is infectious diseases and, often, there are exaggerated fears of dependence with very restrictive drug control policies. In addition, in developing countries, the cost of medicines generally and therefore problems in their procurement, manufacture and distribution, add further barriers to their use.
A treatment gap
In many countries, therefore, there is a treatment gap, meaning that there is a difference between what could be done to relieve pain and what is being done. That gap exists in a number of developed countries, primarily because of poor pain education and the often limited and patchy nature of specialized facilities for pain treatment. Additionally, in developing countries these problems are far greater and the gap is far wider because of the lack of education, access to appropriate drugs for pain relief and facilities for pain management. The treatment gap can be reduced worldwide by improving pain education, increasing facilities for pain treatment and access to pain-relieving drugs. In the case of opioid analgesics, an increase in their availability and the employment of correct protocols is a matter of urgency. Improvements of this kind are possible if use is made of the guidelines published by WHO, together with the
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Service delivery
The management of neurological diseases is primarily a matter for specialist medical and nursing staff, both in developed and developing countries. In contrast, specic facilities for pain management, especially chronic pain management outside neurological centres, are much less well organized and are often absent, especially in developing countries. The relief of pain should be one of the fundamental objectives of any health service. Good practice should ensure provision of evidence-based, high quality, adequately resourced services dedicated to the care of patients and to the continuing education and development of staff. In 1991, an IASP Taskforce on Guidelines for Desirable Characteristics for Pain Treatment Facilities issued denitions of the various types of service in existence for the management of pain by pain clinicians (25). They are given in Box 3.7.3.
Pain clinic
Modality-orientated clinic
Source: (25).
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RESEARCH
Worldwide, research on pain takes place within the disciplines of experimental neurosciences (molecular biology, anatomy, physiology), clinical neurosciences (neurology, neurosurgery, psychiatry), psychology and psychosomatic medicine, anaesthesiology, orthopaedic surgery, public health and community medicine, physical therapy and nursing. The IASP is an interdisciplinary scientic society that fosters interactions between these diverse lines of research via its triennial World Pain Congresses, its scientic journal Pain, and books published by IASP Press (18). Its Special Interest Group on Neuropathic Pain provides a forum for scientic exchange on neuropathic pain and other types of pain that are related to neurological disorders (26).
TRAINING
At present, pain medicine and algesiology are recognized as medical specialties in only a small number of countries (for example Finland, Germany, Turkey and the United Kingdom). Therefore, most medical doctors interested in treating patients for pain spend their residency in one of the existing medical disciplines particularly anaesthesiology but also orthopaedic surgery, neurology or, more rarely, psychiatry or psychosomatic medicine. Pain treatment fellowships are offered by some countries, and IASP has postgraduate training positions. In Germany, a medical subspecialty, specialized pain therapy, is supervised by a licensed training centre and carried out after nishing a residency in one of the traditional medical specialties. More general training in pain management does exist but it is very variable within and between specialist medical areas and between countries. Training programmes for nurses who will specialize in pain management are growing steadily. Such programmes exist mainly in relation to palliative care, post-operative pain management and the work of pain clinics in developed countries but, increasingly, also in countries in the developing world. Physiotherapy is a discipline in which pain management is an integral part of the working day and therefore should be a major aspect of the training of all physiotherapists. Clinical psychologists have a major role in the treatment of chronic pain patients. Usually they specialize in pain management after a period of postgraduate training in general clinical psychology and practise either independently or in specialist pain centres. Very few clinical psychologists are available for work with patients in pain, whether attributable to neurological conditions or not, in developing countries. However, specialist training in pain management for medical practitioners who work in hospitals or the community in developing countries is spreading gradually. IASP has provided a core curriculum for professional education in pain that forms the basis for growing numbers of pain education programmes and is available via open access (27 ).
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REFERENCES
1. International Association for the Study of Pain Sub-Committee on Taxonomy. Pain Terms: a list with denitions and notes on usage, recommended by the IASP Sub-Committee on Taxonomy. Pain, 1979, 6:249252. 2. Merskey H, Bogduk N. Classication of chronic pain: descriptions of chronic pain syndromes and denitions of pain terms, 2nd ed. Seattle, WA, IASP Press, 1994:22. 3. Osterberg A, Boivie J, Thuomas KA. Central pain in multiple sclerosis prevalence and clinical characteristics. European Journal of Pain, 2005, 9:531542. 4. Finnerup N, Jensen TS. Spinal cord injury pain mechanisms and treatment. European Journal of Neurology, 2004, 11:7382. 5. Melzack R. The short-form McGill questionnaire. Pain, 1987, 30:191197. 6. Cruccu G et al. EFNS guidelines on neuropathic pain assessment. European Journal of Neurology, 2004, 11:153162. 7. Gureje O et al. Persistent pain and well-being: a World Health Organization study in primary care. JAMA, 1998, 280:147151. 8. Breivik H, Collett B, Ventafridda V. Survey of chronic pain in Europe: prevalence, impact on daily life and treatment. European Journal of Pain, 2006, 10:287333. 9. Blyth FM et al. Chronic pain in Australia: a prevalence study. Pain, 2001, 89:127134. 10. Eriksen J et al. Epidemiology of chronic non-malignant pain in Denmark. Pain, 2003, 106:221228. 11. Kurtzke JG. Neuroepidemiology. Annals of Neurology, 1984, 16:265277. 12. Ragozzino MW et al. Population based study of herpes zoster and its sequelae. Medicine, 1982, 61:310316. 13. Bowsher D, Lahuerta J, Brock L. Pain patients: a retrospective survey of 1056 cases. The Pain Clinic, 1984, 1:163170. 14. Freynhagen R et al. Screening of neuropathic pain components in patients with chronic back pain associated with nerve root compression: a prospective observational pilot study. Current Medical Research Opinion, 2006, 22:529537. 15. Andersen G et al. Incidence of central post-stroke pain. Pain, 1995, 61:187193. 16. Rasmussen PV et al. Therapeutic outcome in neuropathic pain: relationship to evidence of nervous system lesion. European Journal of Neurology, 2004, 11:545553. 17. Cunningham J, Temple WJ, Mitchell P. Cooperative hernia study. Pain in the post-repair patient. Annals of Surgery, 1996, 224:598602. 18. International Association for the Study of Pain. Seattle, WA (http://www-iasp.pain.org). 19. Achieving balance in national opioids control policy. Guidelines for assessment. Geneva, World Health Organization, 2000 (http://www.medsch.wisc.edu/painpolicy/publicat/00whoabi/00whoabi.htm). 20. Kalso E et al. Recommendations for using opioids in chronic non-cancer pain. European Journal of Pain, 2003, 7:381386. 21. Finnerup NB et al. Algorithm for neuropathic pain treatment: an evidence-based proposal. Pain, 2005, 118:289305. 22. Linton S, Nordin E. A 5-year follow-up evaluation of the health and economic consequences of an early cognitive behavioural intervention for back pain: a randomized controlled trial. Spine, 2006, 31:853858. 23. Flor H, Fydrich T, Turk DC. Efcacy of multidisciplinary pain treatment centres: a meta-analytic review. Pain, 1992, 49:221230. 24. Becker N et al. Treatment outcome of chronic non-malignant pain patients managed in a Danish multidisciplinary pain centre compared with general practice: a randomized controlled trial. Pain, 2000, 84:203211. 25. Loeser JD. Desirable characteristics for pain treatment facilities: report of the IASP taskforce. In: Bond MR, Charlton JE, Woolf CJ, eds. Proceedings of the V1th World Congress on Pain. Amsterdam, Elsevier, 1991:411 417. 26. Special Interest Group on Neuropathic Pain of the International Association for the Study of Pain (http:// www.neupsig.org/). 27. Charlton JE. Core curriculum for professional education in pain. Seattle, WA, IASP Press, 2005 (http://www. iasp-pain.org/CoreCurriculumThirdEdition.htm).
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RECOMMENDED READING
Bakonja M, Rowbotham MC. Pharmacological therapy for neuropathic pain. In: McMahon SB, Koltzenburg M, eds. Wall and Melzacks textbook of pain. London, ElsevierChurchill Livingstone, 2005:10751083. Baron R. Complex regional pain syndromes. In: McMahon SB, Koltzenburg M, eds. Wall and Melzacks textbook of pain. London, ElsevierChurchill Livingstone, 2005:10111027. Boivie J. Central pain. In: McMahon SB, Koltzenburg M, eds. Wall and Melzacks textbook of pain. London, ElsevierChurchill Livingstone, 2005:10571074. Bond MR, Simpson KH. Pain, its nature and treatment. London, ElsevierChurchill Livingstone, 2006. Breivik H, Bond M. Why pain control matters in a world full of killer diseases. Seattle, WA, International Association for the Study of Pain, 2004 (Pain: Clinical Update, 12, No. 4; http://www.iasp-pain.org/ PCUOpen.html, accessed 27 June 2006). Nikolajsen L, Jensen TS. Phantom limb. In: McMahon SB, Koltzenburg M, eds. Wall and Melzacks textbook of pain. London, ElsevierChurchill Livingstone, 2005:961971. Achieving balance in national opioids control policy. Guidelines for assessment. Geneva, World Health Organization, 2000.
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Parkinsons disease is a chronic progressive neurodegenerative disorder of insidious onset, characterized by the presence of predominantly motor symptomatology (bradykinesia, rest tremor, rigidity, and postural disturbances). It is also associated with a diversity of non-motor symptoms, which, together with late-onset motor symptoms (such as postural instability and falls, freezing of gait, speech and swallowing difculties), are presently one of the most difcult challenges the treating physician is faced with when dealing with patients with a long duration of the disease.
In addition to the motor symptomatology of Parkinsons disease (PD) (1), some non-motor symptoms such as hyposmia, rapid eye movements, sleep behaviour disorder, personality changes, pain, paresthesias and depression may be present and may even manifest before the motor symptoms (2). Urinary disturbances, orthostatic hypotension and neuropsychiatric disturbances (dementia, hallucinations and delirium) usually become evident and troublesome after several years in the course of the disease (3). Overt dementia is a late complication that most frequently affects older patients with prolonged disease duration (4). Late-onset motor symptoms include postural instability and falls, freezing of gait, speech and swallowing difculties. The pathophysiology of PD involves the progressive loss of dopamine-containing neurons of the pars compacta of the substantia nigra leading to denervation of the nigrostriatal tract and signicant reduction of dopamine at the striatal level. The consequence of this denervation process is an imbalance in the striato-pallidal and pallido-thalamic output pathways, which is responsible for the major motor decits (5). Genetic predisposing factors in combination with environmental factors are thought to be responsible for the cellular changes leading to progressive neuronal degeneration in which mitochondrial dysfunction, oxidative mechanisms and failure of the protein degradation machinery at the cellular level are probably involved (6). The presence of Lewy bodies (cytoplasmic proteinaceous inclusions) in surviving dopaminergic neurons is the pathological hallmark of PD.
DIAGNOSIS
As there are no denitive biological or imaging markers, diagnosis is at present made through the use of stringent clinical criteria such as those developed by the Brain Bank of the Parkinsons Disease Society in the United Kingdom (7). These criteria are used worldwide and provide for a denite
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Figure 3.8.1
PREVENTION
At present there are no proven therapies for prevention of PD (1). Although there is evidence of the existence of risk and protective factors, these are not strong enough to warrant specic measures in an attempt to diminish risk or enhance protection.
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Intermediate stages
More frequent medical control required May need specialized care Treatment requirements more complex (physical and speech therapy, in some cases surgery) Motor impairment and disability more evident Motor complications (uctuations and dyskinesias)
Advanced stages
May require hospital admissions and participation of other medical specialties (urologist, clinician, gastroenterologist, orthopaedist, psychiatrist; specialized nurses, social workers) May require PD surgery More pronounced motor complications, non motor complications (urinary, autonomic, cognitive impairment, falls) Deglutition disorders
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DELIVERY OF CARE
Diagnosis and delivery of care for the uncomplicated patient can be performed by the general practitioner or family physician only if they are properly trained in the clinical diagnosis of PD and informed on the critical decisions at initiation of treatment which could affect long-term prognosis. In recent years there has been a shift in different regions of the world, in which PD or movement disorders specialists have become involved with delivery of primary care. This change has taken place for several reasons. Initiation of therapy involves crucial therapeutic decisions that may inuence the future course of the disease, thus making it necessary for a more experienced physician to make these decisions. Awareness and education campaigns have brought PD to the forefront, making the patients more demanding in terms of the quality of medical care they seek. The worldwide launching of the Charter for People with Parkinsons Disease in 1997 by the WHO Working Group on Parkinsons Disease (with the support of the European Parkinsons Disease Association), on occasion of the commemoration of World Parkinsons Disease Day. The charter states: People with PD should have the right to be referred to a doctor with special interest in Parkinsons disease (24). In the more advanced stages of the disease, it becomes necessary to resort to more specialized care: most patients are referred to a neurologist who can deal more efciently with the complex issues involved. Depending on the medical customs or organizational aspects of medical care in different countries or regions of the world, consultation with the neurologist is performed at the request of the primary care physician but follow-up rests in the hands of the referring doctor with the occasional assistance of the specialist. In other instances the neurologist, specialized in PD or not, may at this point become the one responsible for the follow-up of the patient. The complicated PD patient presenting with long term motor complications (uctuations and/or dyskinesias; gait disturbances, and speech and deglutition disorders; autonomic dysfunction) will need to be referred to specialists working in a centre that has personnel and facilities for special investigation and treatment. It is also necessary at this stage to seek the help of other medical specialties and in some instances admit the patient to hospital, clinic or other health-care institution, either to perform more complex ancillary studies or specialized surgery, or provide for acute inpatient care. According to published data, almost 40% of advanced PD patients (at 15 years into the course of the disease) need to be admitted to long-term care facilities when the need for complex care exceeds the possibilities of the family or primary caregivers at home (3).
Treatment gap
There are wide gaps in different aspects of PD care. The rst has to do with education and awareness. Knowledge and information about PD is nowhere near as comprehensive as that available for vascular disease or cancer, despite being one of the most frequent neurodegenerative disorders affecting roughly 1% of the population over the age of 65 years. Another very important gap is that related to present limitations of therapy; lack of effective preventive treatments, lack of restorative treatments, and lack of effective therapies to prevent or symptomatically improve long-term complications, both motor and non-motor. The third aspect has to do with the lack of universal access to the presently available wide range of PD medications, surgery and complementary therapies. This is particularly signicant in the poorer or less developed regions of the world, where the lack of properly trained physicians, the high cost of medication and the small number of centres equipped to provide comprehensive management result in inadequate health-care delivery to PD patients.
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RESEARCH
Research in PD is carried out by different organizations. These include government institutions, government-supported research laboratories at universities and private not-for-prot research facilities, and as part of the research and development programmes of the pharmaceutical industry and private corporations. Even though millions of dollars are invested every year in different areas of research, there are few countries in which signicant funds are assigned to research in PD as part of a concerted effort or carefully designed programme with proper supervision and clearly dened goals. Only the European Union and the United States have passed legislation or provided a regulatory framework towards obtaining tangible results in PD within a reasonable time frame. Multiple areas of research are at present focused on nding the answer to the important questions facing the eld of PD. They include research on genetics, pathogenesis, molecular biology and early diagnostic markers (clinical and non-clinical). Therapy is also a main area of research comprising pharmacological therapy as well as non-pharmacological methods (such as surgery, gene therapy, stem cell therapy and trophic factors). An area of research that has not received proper attention is that related to health systems and service delivery. This subject is crucial in resource-poor countries, where the lack of adequate supervision and guidance in the allocation of funds may cause a distortion such as being able to provide sophisticated surgical procedures to a minority of PD patients while more than 80% of them are unable to receive the more basic pharmacological agents.
TRAINING
The core medical curricula in most medical schools throughout the world dedicate little time to providing information on PD and the complexities of its treatment and management. Where available, residency training programmes in neurology provide their trainees with more thorough information and training in this regard. In some parts of the world there are PD and movement disorders post-residency fellowships that allow for the development of more comprehensive education in this neurology subspecialty. In their scientic programmes, most local, regional and international neurology meetings have topics related to PD.
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REFERENCES
1. Nutt JG, Wooten GF. Clinical practice. Diagnosis and initial management of Parkinsons disease. New England Journal of Medicine, 2005, 353:10211027. 2. Chaudhuri KR, Yates L, Martinez-Martin P. The non-motor symptom complex of Parkinsons disease: a comprehensive assessment is essential. Current neurology and neuroscience reports, 2005, 5:275283. 3. Hely MA et al. Sydney Multicenter Study of Parkinsons disease: non-L-dopa-responsive problems dominate at 15 years. Movement disorders, 2005, 20:190199. 4. Emre M. Dementia associated with Parkinsons disease. Lancet Neurology, 2003, 2:229237. 5. Albin RL, Young AB, Penney JB. The functional anatomy of basal ganglia disorders. Trends in Neurosciences, 1989, 12:366375. 6. Gandhi S, Wood NW. Molecular pathogenesis of Parkinsons disease. Human Molecular Genetics, 2005, 2:27492755. 7. Hughes AJ, Daniel SE, Lees AJ. Improved accuracy of clinical diagnosis of Lewy body Parkinsons disease. Neurology, 2001, 57:14971499. 8. Tolosa E, Wenning G, Poewe W. The diagnosis of Parkinsons disease. Lancet Neurology, 2006, 5:7586. 9. Bonifati V. Genetics of Parkinsons disease. Minerva Medica, 2005, 96:175186. 10. Logroscino G. The role of early life environmental risk factors in Parkinson disease: what is the evidence? Environmental Health Perspectives, 2005, 113:12341238. 11. Marras C, Tanner CM. Epidemiology of Parkinsons disease. In: Watts RL, Koller WC, eds. Movement disorders, neurologic principles and practice, 2nd ed. New York, McGraw Hill, 2004:177196. 12. Van Den Eeden SK et al. Incidence of Parkinsons disease: variation by age, gender, and race/ethnicity. American Journal of Epidemiology, 2003, 157:10151022. 13. Ahlskog JE, Muenter MD. Frequency of levodopa-related dyskinesias and motor uctuations as estimated from the cumulative literature. Movement Disorders, 2001, 16:448458. 14. Bloem BR et al. Falls and freezing of gait in Parkinsons disease: a review of two interconnected, episodic phenomena. Movement Disorders, 2004, 19:871884. 15. Hoehn MM, Yahr MD. Parkinsonism: onset, progression and mortality. Neurology, 1967, 17:427442. 16. Herlofson K et al. Mortality and Parkinson disease: a community-based study. Neurology, 2004, 62:937 942. 17. Alves G et al. Progression of motor impairment and disability in Parkinson disease: a population-based study. Neurology, 2005, 65:14361441. 18. Schrag A et al. Caregiver burden in Parkinsons disease is closely associated with psychiatric symptoms, falls, and disability. Parkinsonism Related Disorders, 2006, 12:3541. 19. Goetz CG et al. Evidence-based medical review update: pharmacological and surgical treatments of Parkinsons disease: 2001 to 2004. Movement Disorders, 2005, 20:523539. 20. Metman LV, OLeary ST. Role of surgery in the treatment of motor complications. Movement Disorders, 2005, 20(Suppl. 11):S45S56. 21. Schapira AH. Present and future drug treatment for Parkinsons disease. Journal of Neurology, Neurosurgery and Psychiatry, 2005, 76:14721478. 22. Lang AE et al. Progress in clinical neurosciences: a forum on the early management of Parkinsons disease. Canadian Journal of Neurological Sciences, 2005, 32:277286. 23. Huse DM et al. Burden of illness in Parkinsons disease. Movement Disorders, 2005, 20:14491454. 24. Charter for People with Parkinsons Disease. European Parkinsons Disease Association, 2006 (www.epda. eu.com/worldPDDay/2006_.shtm). 25. Atlas: country resources for neurological disorders 2004. Geneva, World Health Organization, 2004.
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RECOMMENDED READING
Alves G et al. Progression of motor impairment and disability in Parkinson disease: a population-based study. Neurology, 2005, 65:14361441. Emre M. Dementia associated with Parkinsons disease. Lancet Neurology, 2003, 2:229237. Goetz CG et al. Evidence-based medical review update: pharmacological and surgical treatments of Parkinsons disease: 2001 to 2004. Movement Disorders, 2005, 20:523539. Hely MA et al. Sydney Multicenter Study of Parkinsons disease: non-L-dopa-responsive problems dominate at 15 years. Movement Disorders, 2005, 20:190199. Huse DM et al. Burden of illness in Parkinsons disease. Movement Disorders, 2005, 20:14491454. Lang AE et al. Progress in clinical neurosciences: a forum on the early management of Parkinsons disease. Canadian Journal of Neurological Sciences, 2005, 32:277286. Marras C, Tanner CM. Epidemiology of Parkinsons disease. In: Watts RL, Koller WC, eds. Movement disorders, neurologic principles and practice, 2nd ed. New York, McGraw Hill, 2004:177196. Nutt JG, Wooten GF. Clinical practice. Diagnosis and initial management of Parkinsons disease. New England Journal of Medicine, 2005, 353:10211027. Schapira AH. Present and future drug treatment for Parkinsons disease. Journal of Neurology, Neurosurgery and Psychiatry, 2005, 76:14721478. Schrag A et al. Caregiver burden in Parkinsons disease is closely associated with psychiatric symptoms, falls, and disability. Parkinsonism Related Disorders, 2006, 12:3541.
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3.9 Stroke
151 Diagnosis and classication 152 Risk factors and prevention strategies 153 Course and outcome 154 Epidemiology and magnitude 156 Mortality, disability and burden 157 Treatment, management and rehabilitation 159 Secondary prevention 160 Delivery of care 161 Partnerships within and beyond the health system 161 Research 162 Conclusions and recommendations
Stroke is one of the main noncommunicable diseases of public health importance. After coronary heart disease and cancer, stroke is the most common cause of death in most industrialized countries. In general terms, stroke is a sudden neurological decit owing to localized brain ischaemia or haemorrhage. Most strokes are attributed to focal occlusion of the cerebral blood vessel (ischaemic stroke) and the remainder are the result of rupture of a blood vessel (haemorrhagic stroke).
WHO denes stroke as the clinical syndrome of rapid onset of focal (or global, as in subarachnoid haemorrhage) cerebral decit, lasting more than 24 hours (unless interrupted by surgery or death), with no apparent cause other than a vascular one (1). In developed countries up to 7580% of strokes are attributed to brain ischaemia, while 1015% of strokes represent primary intracerebral haemorrhage (ICH) and approximately 510% are subarachnoid haemorrhage (SAH).
152
Atherothromboembolism 50%
153
Dependent
Dead
154
Oyabe, Japan
Melbourne, Australia
Perth, Australia
Rochester, Minn
Uzhgorod, Ukraine
400
200
100
0 All age All age- and sex-standardized incidence Age 4584 years
Warsaw, Poland
Barbados
China
Tbilisi, Georgia
Belluno, Italy
Iquique, Chile
300
Frederiksberg, Denmark
Innherrd, Norway
Tartu, Estonia
LAquila, Italy
Dijon, France
Sderhamn, Sweden
Arcadia, Greece
Tbilisi, Georgia
155
156
% of population
60 40 20 0
dies
Unspecied stroke
Subarachnoid haemorrhage
Intracerebral haemorrhage
Ischaemic stroke
Beijin
, Italy
Franc e Perth, Austra lia Umbr ia, Ita ly Roche ster, M Oxfor inn dshire , Unite d King dom
Austra lia
nmark
ila, Ita ly
Norw ay
o, Italy
s, Italy
, Italy
den
rman
dos
ce
ia, Gre e
Barba
, Swe
Vibo V alentia
en, Ge
rg, De
Dijon,
Bellun
Island
West In
Aosta
Iquiqu
L'Aqu
hamn
Arcad
urne,
Erlang
Aeolia n
Frenc h
iksbe
Innhe
Frede r
Soder
Melbo
Martin
ique,
and X
iangy
rred,
157
158
159
Rehabilitation
Stroke survivors frequently suffer from neurological impairments, functional decits and handicap. Stroke rehabilitation is the restoration of patients to their previous physical, mental and social capability. Rehabilitation may have an effect upon each level of expression of stroke-related neurological dysfunction. It is of extreme importance to start rehabilitation as soon as possible after stroke onset. In stroke units, in cases of severe stroke with decreased level of consciousness, passive rehabilitation is started and active rehabilitation is initiated in patients with preserved consciousness. Several organizational models of stroke rehabilitation exist. Rehabilitation is typically started in hospital and followed by short-term rehabilitation in the same unit (comprehensive stroke units), rehabilitation clinics or outpatient settings. A multidisciplinary team approach and involvement and support to carers are key features also in the long term. Several studies have shown that different types of rehabilitation services improve outcome, but less is known about the optimum intensity and duration of specic interventions. The scientic basis for rehabilitation and neural repair has increased considerably, and reorganization of activation patterns in the brain after injury may be monitored by functional imaging studies (PET, functional MRI). Because of a lack of modern rehabilitation equipment and organization of services in the resource-poor countries, proper and prompt rehabilitation (both passive and active) are often decient in the majority of developing countries.
SECONDARY PREVENTION
Almost a third of all strokes occur in patients who have previously had a stroke, and about 15% of all strokes are preceded by TIAs. Recurrent cerebrovascular events thus contribute substantially to the global burden of the disease. Recently, an encouraging amount of new information has emerged to modify clinical practice in secondary prevention of ischaemic stroke and TIA. Lowering of blood pressure has been known for years to reduce the risk of rst stroke. The recent trials show that the same applies for secondary stroke prevention, whether ischaemic or haemorrhagic. The relative risk reduction of about a quarter is associated with a decrease in blood pressure of 9 mm Hg systolic and 4 mm Hg diastolic. Although higher plasma cholesterol concentrations do not seem to be associated with increased stroke risk, it has been suggested that lowering the concentration may decrease the risk. The risk of stroke or myocardial infarction, and the need for vascular procedures, is also reduced by a decrease in cholesterol concentration but it is still debated whether statins are effective in stroke prevention. Aspirin, given to TIA/ischaemic stroke patients, reduces the relative risk of stroke and other important vascular events by about 13%. Compared with aspirin, clopidogrel reduces the risk of stroke and other important vascular events from about 6.0% (aspirin) to 5.4% (clopidogrel) per year. The combination of aspirin and modied-release dipyridamole may also be more effective than aspirin alone. Long-term oral anticoagulants for TIA/ischaemic stroke patients in atrial brillation reduce the annual risk of stroke from 12% to 4%. Anticoagulation may be indicated for about 20% of patients with TIA/ischaemic stroke who have high-risk sources of embolism from the heart to the brain, mostly atrial brillation. Stroke risk ipsilateral to a recently symptomatic carotid stenosis increases with degree of stenosis, and is highest soon after the presenting event. Carotid endarterectomy reduces the risk of stroke substantially in such patients. The recent evidence suggests that the benet from surgery is also greater in men, patients aged 75 years, and those randomized and operated upon within two weeks after their last ischaemic event.
160
DELIVERY OF CARE
Developed countries are able to provide accessible health-care services to their people but, even in these countries, services are far from optimal. In developing countries, however, cultural beliefs and failure to recognize stroke symptoms may have an impact on the number of patients seeking medical attention, and those who do come may present after complications have developed. In the United States, approximately 60% of stroke patients present within three hours of stroke onset, while in Europe 4056% arrive at hospital within six hours. In Turkey, only 40% of stroke patients are seen in the hospital within 12 hours (2). Economic policies of developing countries may not allow large investments in health care, hospitals, brain scanners or rehabilitation facilities. Health care in the acute phase of stroke is the most costly component of the care of stroke patients; in low-resource countries hospital care of even a small proportion of all patients with stroke accounts for a disproportionately high share of total hospital costs. Stroke units, which have been shown to reduce mortality, morbidity and other unfavourable outcomes without necessarily increasing health costs, are available in very few developing countries. Costs of consultation, investigation, hospitalization and medication may be beyond the means of poor people, especially those who do not have welfare benets or medical insurance plans. This seriously hampers the provision of care to patients who are otherwise able to seek medical attention. Although hospital care represents a large proportion of the costs of stroke, institutional care also contributes signicantly to overall stroke care costs. Most developing countries do not have well-established facilities for institutional care. The bulk of long-term care of the stroke patient is likely to fall on community services and on family members, who are often ill equipped to handle such issues. There is thus a need for appropriate resource planning and resource allocation to help families cope with a stroke-impaired survivor.
161
RESEARCH
Stroke research is grossly underfunded even in developed countries (21). One of the major problems of stroke epidemiology is the lack of good-quality epidemiological studies in developing countries, where most strokes occur and resources are limited. To address the problem of accurate and comparable data in these countries, an approach to increase the quality of the data collected for stroke surveillance has recently been proposed by WHO. This exible and sustainable system includes three steps: standard data acquisition (recording of hospital admission rates for stroke), expanded population coverage (calculation of mortality rates by the use of death certicates or verbal autopsy), and comprehensive population-based studies (reports of nonfatal events to calculate incidence and case-fatality). These steps could provide vital basic epidemiological estimates of the burden of stroke in many countries around the world (20).
162
6 7 8
10
163
REFERENCES
1. Hatano S. Experience from a multicentre stroke register: a preliminary report. Bulletin of the World Health Organization, 1976, 54:541553. 2. Poungvarin N. Stroke in the developing world. Lancet, 1998, 352(Suppl. 3): 1922. 3. Warlow C et al. Stroke. Lancet, 2003, 362:12111224. 4. Goldstein LB et al. Primary prevention of ischemic stroke: a guideline from the American Heart Association/ American Stroke Association Stroke Council. Stroke, 2006, 37:1583. 5. Mackay J, Mensah GA. The atlas of heart disease and stroke. Geneva, World Health Organization, 2004. 6. WHO CVD-risk management package for low- and medium-resource settings. Geneva, World Health Organization, 2002. 7. Feigin VL et al. Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. Lancet Neurology, 2003, 2:4353. 8. Thorvaldsen P et al. Stroke trends in the WHO MONICA project. Stroke, 1997, 28:500506. 9. Sarti C et al. International trends in mortality from stroke, 1968 to 1994. Stroke, 2000, 31:15881601. 10. Rothwell PM et al. Changes in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet, 2004, 363:19251933. 11. Murray CJL, Lopez AD. Mortality by cause for eight regions of the world: global burden of disease study. Lancet, 1997, 349:12691276. 12. The world health report 2004 Changing history. Geneva, World Health Organization, 2004 (Statistical Annex). 13. Warlow CP. Epidemiology of stroke. Lancet, 1998, 352(Suppl. 3):14. 14. Preventing chronic diseases: a vital investment. Geneva, World Health Organization, 2005. 15. The Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for stroke (Cochrane Review). Cochrane Database of Systematic Reviews, 2002, 1:CD000197. 16. Brott T, Bogousslavsky J. Treatment of acute ischaemic stroke. New England Journal of Medicine, 2000, 343:710722. 17. Hankey GJ, Warlow CP. Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations. Lancet, 1999, 354:14571463. 18. Mendis S et al. WHO study on Prevention of Recurrences of Myocardial Infarction and Stroke (WHOPREMISE). Bulletin of the World Health Organization, 2005, 83:820829. 19. Prevention of recurrent heart attacks and strokes in low and middle income populations: evidence-based recommendations for policy-makers and health professionals. Geneva, World Health Organization, 2003. 20. Bonita R et al. The Global Stroke Initiative. Lancet Neurology, 2004, 3:391393. 21. Pendlebury ST et al. Underfunding of stroke research: a Europe-wide problem. Stroke, 2004, 35:23682371.
RECOMMENDED READING
Brown MM, Markus H, Oppenheimer S. Stroke medicine. Abingdon, Taylor & Francis, 2006. Dobkin B. Strategies for stroke rehabilitation. Lancet Neurology, 2004, 3:526536. European Stroke Initiative recommendations for stroke management Update 2003. Cerebrovascular Disease, 2003, 16:311337. Ginsberg M, Bogousslavsky J, eds. Cerebrovascular disease: pathophysiology, diagnosis and management. Malden, Blackwell Science, 1998. Leys D et al. Poststroke dementia. Lancet Neurology, 2005, 4:752750. Intercollegiate Stroke Working Party. National clinical guidelines for stroke, 2nd ed. London, Royal College of Physicians, 2004. Rothwell PM, Buchan A, Johnston SC. Recent advances in management of transient ischaemic attacks and minor ischaemic strokes. Lancet Neurology, 2006, 5:323331. Sacco R et al. Guidelines for prevention of stroke in patients with ischaemic stroke or transient ischaemic attack. AHA/ASA guidelines. Stroke, 2006, 37:577617. Management of patients with stroke. Rehabilitation, prevention and management of complications, and discharge planning. A national clinical guideline. Edinburgh, Scottish Intercollegiate Guidelines Network, 2002. Warlow CP et al. Stroke: a practical guide to management, 2nd ed. Oxford, Blackwell Science, 2000. WHO CVD-risk management package for low- and medium-resource settings. Geneva, World Health Organization, 2002. Prevention of recurrent heart attacks and strokes in low and middle income populations: evidence-based recommendations for policy-makers and health professionals. Geneva, World Health Organization, 2003. Preventing chronic diseases: a vital investment. Geneva, World Health Organization, 2005.
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Traumatic brain injury is the leading cause of death and disability in children and young adults 173 Infrastructure and human resources for care around the world and is involved in nearly half of 173 Research all trauma deaths. Many years of productive life are lost, and many people have to suffer years of 173 Conclusions and recommendations disability after brain injury. In addition, it engenders great economic costs for individuals, families and society. Many lives can be saved and years of disability spared through better prevention.
171 Prevention and education
More and better epidemiological data can help in tailoring effective preventive measures against traumatic brain injury (TBI), with particular emphasis on reducing the impact of road trafc accidents. The world is facing a silent epidemic of road trafc accidents in the developing countries: by 2020, road trafc crashes will have moved from ninth to third place in the world ranking of the burden of disease and will be in second place in developing countries. A lot can be done to reduce the devastating consequences of TBIs. Systematic triage of patients can lead to important economic savings and better use of scant hospital resources. More standardized pre-hospital and in-hospital care, to minimize secondary brain injury, can improve outcomes substantially.
165
Triage
Classication into these categories based on clinical assessment alone must be supported by the results of a computerized tomography (CT) examination in many cases, or a skull X-ray if a CT scanner is not available. A fracture detected on the skull X-ray images indicates an increased risk of deterioration, and the patient will need admission. A CT scan reveals a skull fracture more clearly than an ordinary X-ray examination will do. In addition, it visualizes the bleeding, bruising and swelling of actual brain injury: CT signs of brain damage are present in one third of the mild cases, two thirds of the moderate cases and all the severe cases (24).
166
Prevalence
Prevalence of TBI measures the total number of injuries at a point in time or in a period interval; the calculation should include all those with TBI sequelae such as impairments, disabilities, handicaps or complaints, plus all the newly diagnosed cases at the dened time or time interval. Estimates from the United States indicate that 12% of the population, i.e. around ve million people, live with a TBI disability (67 ). Many disabled people have neurobehavioural problems. It is therefore no exaggeration to describe TBI disability as an enormous public health problem (6). Information on how sequelae develop (diminish or increase) over time is scarce (8); better data on prevalence would certainly be useful for improved planning of rehabilitation needs.
Mortality
Case-fatality rate in different parts of the world. The average European pre-hospital case-fatality rate was 8%, while the in-hospital rate was 3%, i.e. a total rate of 11 deaths per 100 cases of TBI, all grades of severity included. The in-hospital rate varies from 2.4 in Australia to 6.2 in the United States and 11 in China, Province of Taiwan (5). Admission policies may inuence these rates. About one third of the hospitalized patients dying after TBI had talked at some time after the injury: this is an indication that some of them might have been saved (9). Mortality rate per 100 000 population per year is more informative than the case-fatality rate. The average European rate was estimated to be 15 TBI-associated deaths per 100 000 population per year (5). The rate is around 10 in Scandinavia, 20 in India, 30 in the United States, 38 in China, Province of Taiwan, 81 in South Africa and 120 in Colombia (10). In three of the four Nordic
Figure 3.10.1 Mortality rates associated with traumatic brain injury, Nordic countries, 19872000
26 Finland 24 Denmark Norway Sweden
22 20 18 16 14 12 10 8 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Source: (11).
Year
167
Disability
Traumatic brain injury is the leading cause of disability in people under 40 years of age. Disability can be classied in a simple fashion using the Glasgow Outcome Scale (see Table 3.10.2):
Description
Awake but not aware Conscious but dependent Independent but disabled May have minor sequelae
Thornhill and colleagues have recently estimated the annual incidence of disability after TBI (moderate and severe disability together) to be approximately 100 per 100 000 population per year. Their ndings revealed a higher incidence than indicated in previous reports, particularly in patients with mild TBI (1). Most patients (90%) had sustained a mild head injury, while a few had suffered moderate (5%) or severe (3%) brain injury. Half of the survivors were disabled after mild or moderate TBI, while three quarters of survivors were disabled after a severe injury. Even among young patients with mild injuries and a good pre-injury status, one third failed to achieve a good recovery. Moderate disability after TBI is 34 times more common than severe disability. Severe disability after TBI is reported in 1520 per 100 000 population per year (8). Mostly, patients with severe disability will have a combined mental and physical handicap. The rarest form of disability after TBI is the vegetative state. It may be transitory, subsiding after a month or so, but may persist in many cases. The persistently vegetative patient needs articial nutrition and hydration and will have a markedly reduced life span, i.e. 25 years. In some cases, complicated ethical and legal discussions arise about the purpose of continuing life-sustaining treatment. Disability after moderate or severe TBI may take various forms: Mental sequelae with personality change, memory disorders, reduced reasoning power and apathy (9). A defective recent memory may be particularly incapacitating. Disturbed motor function of arm or leg. Speech disturbances. Epilepsy, which may develop years after the primary injury, is seen in 15% of patients.
Recovery
Some patients continue to recover for years after a TBI, but 90% reach their denitive GOS level after six months (9). Elderly patients with TBI are known to have a slower rate of functional recovery, longer stays in rehabilitation and greater levels of disability with comparable injuries.
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169
170
171
COSTS
Any information that is available about the economic consequences of TBI is mostly related to costs of hospitalization, which probably constitute only a relatively small part of the total costs. According to Berg and colleagues (10), TBI-associated costs can be subdivided as follows: direct costs: hospitalization, outpatient care, rehabilitation; indirect costs: lost productivity, in particular after moderate or severe injuries; intangible costs to patients, families and friends: related to death or reduced quality of life.
172
Education
Educational activities should comprise age-oriented educational programmes including personal computer games, medical and paramedical training in neurotrauma, development of an Advanced Life Support in Brain Injury (ALSBI), and multimedia educational campaigns on safety of motor vehicles. The creation of foundations for the relatives of victims of injuries or associations for education and the prevention of TBI should be strengthened. The ALSBI course objectives could be summarized as follows: educate pre-hospital and emergency service physicians in the care of acute neurological patients;
173
RESEARCH
Research in the eld of TBI should cover the following subjects: Epidemiology, with particular emphasis on more standardized measures, to allow comparisons between regions and a valid evaluation of care and prevention. The management of TBI patients with pre-hospital care, in-hospital care and rehabilitation. Such studies should range from logistics, quality of life studies, pathophysiology, etc. to evaluation of various aspects of multidisciplinary rehabilitation.
174
REFERENCES
1. Thornhill S et al. Disability in young people and adults one year after head injury: prospective cohort study. BMJ, 2000, 320:16311635. 2. Thiruppathy SP, Muthukumar N. Mild head injury: revisited. Acta Neurochirugica, 2004, 146:10751082. 3. Rimel RW et al. Moderate head injury: completing the clinical spectrum of brain trauma. Neurosurgery, 1982, 11:344351. 4. Masson F et al. Epidemiology of traumatic comas: a prospective population-based study. Brain Injury, 2003, 17:279293. 5. Tagliaferri F et al. A systematic review of brain injury epidemiology in Europe. Acta Neurochirugica, 2006, 148:255268. 6. Kelly DF, Becker DP. Advances in management of neurosurgical trauma: USA and Canada. World Journal of Surgery, 2001, 25:11791185. 7. Fakhry SM et al. Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges. Journal of Trauma, 2004, 56:492500. 8. Fleminger S, Ponsford J. Long term outcome after traumatic brain injury. BMJ, 2005, 331:14191420. 9. Jennett B, Lindsay KW. An introduction to neurosurgery, 5th ed. Oxford, Butterworth-Heinemann Ltd., 1994. 10. Berg J, Tagliaferri F, Servadei F. Cost of trauma in Europe. European Journal of Neurology, 2005, 12(Suppl. 1):8590. 11. Sundstrm T, Sollid S, Wester K. Deaths from traumatic brain injury in the Nordic countries, 19872000. Tidsskrift for den Norske laegeforening, 2005, 125:13101312. 12. Roberts I, Mohan D, Abassi K. War on the roads. BMJ, 2002, 324:11071108. 13. Nantulya VM, Reich MR. The neglected epidemic: road trafc injuries in developing countries. BMJ, 2002, 324:11391141. 14. Iftikhar AR, Vohra AH, Ahmed M. Neurotrauma in Pakistan. World Journal of Surgery, 2001, 25:12301237. 15. Adekoya N et al. Surveillance for traumatic brain injury deaths United States, 19891998. MMWR CDC Surveillance Summaries, 2002, 51:114. 16. Stone JL, Lichtor T, Fitzgerald L. Gunshot wounds to the head in civilian practice. Neurosurgery, 1996, 37:11041112. 17. Basso A et al. Advances in management of neurosurgical trauma in different continents. World Journal of Surgery, 2001, 25:11741178. 18. Durkin MS et al. The epidemiology of urban pediatric neurological trauma: evaluation of, and implications for, injury prevention programs. Neurosurgery, 1998, 42:300310. 19. Servadei F, Teasdale G, Merry G. Dening acute mild head injury in adults: a proposal based on prognostic factors; diagnosis, and management. Journal of Neurotrauma, 2001, 18:657664. 20. Norlund A et al. Immediate computed tomography or admission for observation after mild head injury: cost comparison in randomised controlled trial. BMJ, 2006, 333:469. 21. Watts DD et al. An evaluation of the use of guidelines in prehospital management of brain injury. Prehospital Emergency Care, 2004, 8:254261. 22. Kay A, Teasdale G. Head injury in the United Kingdom. World Journal of Surgery, 2001, 25:12101220. 23. Diringer MN. What do we really understand about head injury? Neurocritical Care, 2005, 2:3. 24. Taricco M, Liberati A. Rehabilitation of traumatic brain injury. Europa Medicophysica, 2006, 42:6971. 25. Turner-Stokes L et al. Multi-disciplinary rehabilitation for acquired brain injury in adults of working age. Cochrane Database of Systematic Reviews, 2005, 3:CD004170. 26. Dora C. A different route to health: implications for transport policies. BMJ, 1999, 318:16861689.
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RECOMMENDED READING
Berg J, Tagliaferri F, Servadei F. Cost of trauma in Europe. European Journal of Neurology, 2005, 12(Suppl. 1):8590. Cooper PR, Golnos J, eds. Head injury, 4th ed. New York, McGraw Hill, 2000. Ingebrigtsen T, Romner B, Kock-Jensen C. Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee. Journal of Trauma, 2000, 48:760766. Tagliaferri F et al. A systematic review of brain injury epidemiology in Europe. Acta Neurochirugica, 2006, 148:255268. Turner-Stokes L et al. Multi-disciplinary rehabilitation for acquired brain injury in adults of working age. Cochrane Database of Systematic Reviews, 2005, 3:CD004170. Guidelines for prehospital management of traumatic brain injuries. New York, Brain Trauma Foundation, 2000 (http://www2.braintrauma.org/guidelines/index.php). Management and prognosis of severe traumatic brain injuries. New York, Brain Trauma Foundation, 2000 (http://www2.braintrauma.org/guidelines/index.php).
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CHAPTER 4
177
The relationship between neurology and public health has not been adequately explored to date. This report provides considerable detail 179 Recommendations for action about the increasing global public health importance of various common neurological disorders. Public health interventions that may be applied in an attempt to reduce their occurrence and consequences have been considered. A clear message emerges: unless immediate action is taken globally, the neurological burden is expected to become an even more serious and unmanageable threat to public health.
This nal chapter highlights a number of overall patterns and themes that cut across the neurological disorders discussed in the previous chapters. It reiterates what is known about neurological disorders and makes the case for a public health approach; it then considers what can be done and provides a set of recommendations for decision-makers and health-care providers. tions to older and ageing ones, causing increases in the neurological disorders such as Alzheimer and other dementias and Parkinsons disease. As a consequence, many low income countries face the double burden of a continuing high level of infections including some that result in neurological disorders (e.g. HIV and malaria) and increases in noncommunicable diseases. The number of people with neurological disorders is estimated to increase considerably in years to come. It is forecast that the number of people affected by dementia (already counted in tens of millions) will double every 20 years. While predictions point to higher risk among poor people, children, adolescents and elderly persons, no population group is immune to neurological disorders. Because most of the neurological disorders result in long-term disability and many have an early age of onset, measures of prevalence and mortality
178
179
180
neurological disorders: conclusions and recommendations 4. Strengthen neurological care within the existing health systems
The most promising approach for reducing the burden of neurological disorders in developing countries is a comprehensive system of primary health care: primary care services supported by secondary and tertiary care facilities, physicians and specialists. Primary care is the point of entry for the vast majority of people seeking medical care indeed, for many people it is their sole access to medicine. Moreover, because primary care teams work in the community, they are well placed to recognize factors such as stigma, family problems and cultural factors that affect treatment for neurological disorders. Thus, primary care is the logical setting in which neurological disorders need to be dealt with. The important role of primary care is also founded on recognition that decisions in primary care take account of patient-related factors family medical history and patients individual expectations and values of which the continuity and long-term relationships of primary care generate awareness, while promoting trust and satisfaction among patients. For example, effective management of headache disorders can be provided in primary care for all but a very small minority of patients, as the common headache disorders require no special investigation and they can be diagnosed and managed with skills generally available to health-care professionals working in primary care settings. A careful analysis is required of what is and what is not possible for the treatment and care of neurological disorders at different levels of care. It is thus very important to establish a referral system for management of severe cases and patients requiring access to diagnostic and technological expertise. What is needed is a continuing, seamless care approach to handle the long-term nature of neurological disorders and the call for ongoing care.
181
182
This report endeavours to contribute to the knowledge base regarding public health aspects of neurological disorders. It is hoped that it will inspire and facilitate increased cooperation, innovation and commitment in preventing neurological disorders and providing the best possible care for people suffering from them.
annexes
183
Annex 1
To aid in cause of death and burden of disease analyses, the Member States of the World Health Organization (WHO) have been divided into ve mortality strata on the basis of their levels of mortality of children under ve years of age (5q0) and of males 1559 years old (45q15). The classication of WHO Member States into mortality strata was carried out using population estimates for 1999 (from the United Nations Population Division, 1998) and estimates of 5q0 and 45q15 based on WHO analyses of mortality rates for 1999. Quintiles of the distribution of 5q0 (both sexes combined) were used to dene a very low child mortality group (1st quintile), a low child mortality group (2nd and 3rd quintiles) and a high child mortality group (4th and 5th quintiles). Adult mortality 45q15 was regressed on 5q0 and the regression line used to divide countries with high child mortality into high adult mortality (stratum D) and very high adult mortality (stratum E). Stratum E includes the countries in sub-Saharan Africa where HIV/AIDS has had a very substantial impact. The following table summarizes the ve mortality strata. When these mortality strata are applied to the six WHO regions, they produce 14 subregions, which are used throughout this document and its Annexes to present results. The mortality strata to which WHO Member States are classied are listed below. This classication has no ofcial status and is for analytical purposes only.
The total number of WHO Member States rose to 193 in 2006 with the addition of the Republic of Montenegro.
184
Afr-E
Americas (AMR)
Amr-A Amr-B
Americas with very low child and very low adult mortality Americas with low child and low adult mortality
Americas with high child and high adult mortality South-East Asia with low child and low adult mortality South-East Asia with high child and high adult mortality Europe with very low child and very low adult mortality
High mortality developing Low mortality developing High mortality developing Developed
Eur-B
Developed
Europe with low child and high adult mortality Eastern Mediterranean with low child and low adult mortality Eastern Mediterranean with high child and high adult mortality Western Pacic with very low child and very low adult mortality Western Pacic with low child and low adult mortality
Developed Low mortality developing High mortality developing Developed Low mortality developing
* Following improvements in child mortality over recent years, Egypt meets criteria for inclusion in subregion Emr-B with low child and low adult mortality. Egypt has been included in Emr-D for the presentation of subregional totals for mortality and burden to ensure comparability with The World Health Report and other WHO publications. ** Although Cambodia, the Lao Peoples Democratic Republic and Papua New Guinea meet criteria for high child mortality, they have been included in the Wpr-B subregion with other developing countries of the Western Pacic Region for reporting purposes.
annexes
185
Annex 2
Income category
High
Upper middle
Lower middle
Low
Not included
Note: Categories are based on the income categories published in 2003 World development indicators (Washington, DC, The World Bank, 2003). Countries are divided according to 2001 GNI per capita, calculated using the World Bank Atlas method. The groups are: low income, US$ 745 or less; lower middle income, US$ 7462975; upper middle income, US$ 29769205; and high income, US$ 9206 or more. This differs from the list currently available on the World Bank web site because that list has been recently amended.
186
Annex 3
Global Burden of Disease cause categories, sequelae and case definitions for neurological disorders
For the purpose of calculation of global burden of disease (GBD) estimates for this document, the neurological disorders were included from two categories: neurological disorders within the neuropsychiatric category, and neurological disorders from other categories. Neurological disorders within the neuropsychiatric category refer to the cause category listed in Group II under neuropsychiatric disorders and include epilepsy, Alzheimer and other dementias, Parkinsons disease, multiple sclerosis and migraine. Neurological disorders from other categories include diseases and injuries which have neurological sequelae and are listed elsewhere in cause category Groups I, II and III. The table below provides the complete list used for calculation of GBD estimates for neurological disorders.
Sequelae
Case denition
Neurological disorders in the neuropsychiatric category Epilepsy Cases Cases meeting ILAE denition Cases meeting ICD-10 criteria for alcohol dependence and harmful use (F10.1 and F10.2), excluding cases with comorbid depressive episode Mild, moderate and severe Alzheimers disease, senile and other dementias Cases meeting clinical criteria for Parkinsons disease Cases of chronic or intermittent relapsing multiple sclerosis Cases meeting IHS denition for migraine
Neurological disorders in other categories Cerebrovascular disease First-ever stroke cases First-ever stroke according to WHO denition (includes subarachnoid haemorrhage but excludes transient ischaemic attacks, subdural haematoma, and haemorrhage or infarction attributable to infection or tumour). Persons who survive more than 28 days after rst-ever stroke. Viral infection characterized by acute accid paralysis and proven by isolation of poliovirus from stool Neonatal: infection with Clostridium tetani in infants less than 30 days old with progressive difculty and inability to feed because of trismus, generalized stiffness, spasms and opisthotonus Non-neonatal: infection with Clostridium tetani in non-neonates with initial localized spasms leading to general rigidity, opisthotonus and risus sardonicus
annexes
GBD cause category
Meningitis
187
Sequelae
Case denition
Acute bacterial disease with sudden onset and fever, intense headache, nausea, vomiting, neck stiffness and in meningococcal disease petechial rash with pink macules; the disease must be accompanied by laboratory evidence (in cerebrospinal uid or blood) of Neisseria meningitidis, Streptococcus pneumoniae or Haemophilus inuenzae type B Seizures of any type that were present at least six months after hospitalization, RESULTING from meningitis Motor decit spasticity or paresis of one or more limbs, RESULTING from meningitis IQ of 70 or below RESULTING from meningitis Mosquito-borne encephalitis caused by JE virus Reduced cognitive function resulting from encephalitis attributable to JE virus Neurological decits resulting from encephalitis attributable to JE virus Acute and chronic infection with Treponema pallidum Late stage of the disease with varied neurological manifestations Acute bacterial infection of the respiratory tract with Bordetella pertussis or parapertussis Degenerative disease of the brain, which in pertussis is usually a result of hypoxia, leading to mental retardation Acute disease caused by toxin-producing Corynebacterium diphtheriae Polyneuritis involving both cranial and peripheral nerve palsies, which are largely reversible Infectious disease caused by protozoa of the genus Plasmodium Includes hemiplegia, aphasia, ataxia and cortical blindness Chronic disease resulting from infection with Mycobacterium leprae Grade 1 and 2 of WHO grades of disability for leprosy Loss of reexes and of vibration; damage and dysfunction of sensory, motor or autonomic nerves attributable to diabetes Limited physical and mental ability to perform most activities in all of the following areas: recreation, education, procreation or occupation Any of the following attributable to iodine deciency: bilateral hearing loss, delay of walking ability, mild intellectual impairment Hypothyroid cretinism: hypothyroidism and stunting as a RESULT of iodine deciency Neurological cretinism: mental deciency (IQ below 70), deaf-mutism, and spastic paralysis as a RESULT of iodine deciency Some but not all features of full cretinism as a RESULT of iodine deciency Includes crashes and pedestrian injuries attributable to motor vehicles
Seizure disorder Motor decit Mental retardation Japanese encephalitis Cognitive impairment Neurological sequelae Syphilis Tertiary neurological Pertussis Encephalopathy Diphtheria Neurological complications Malaria Neurological sequelae Leprosy Disabling leprosy Diabetes mellitus Proteinenergy malnutrition Iodine deciency Neuropathy Developmental disability Mild developmental disability Cretinoidism
Cretinism Road trafc accidents Fractured skull long-term Spinal cord injury long-term Intracranial injury long-term Injured nerves long-term Poisonings Fractured skull long-term Spinal cord injury long-term Intracranial injury long-term Injured nerves long-term Falls Fractured skull long-term Spinal cord injury long-term Intracranial injury long-term Injured nerves long-term Fires Fractured skull long-term Spinal cord injury long-term Intracranial injury long-term Injured nerves long-term
Most of the sequelae of res are the result of burns. Some individuals, however, jump from buildings or are otherwise injured during res.
188
Sequelae
Case denition
Other than drowning and near-drowning rates, the only other major disabling sequela from near-drowning included is quadriplegia
This is not a residual category, but includes injuries attributable to environmental factors, machinery and electrical equipment, cutting and piercing implements, and various other external causes of unintentional injury Suicide attempts, whether or not resulting in death
Self-inicted injuries
annexes
189
Annex 4
Table A.4.1 Burden of neurological disorders, in DALYs, by cause, WHO region and mortality stratum, projections for 2005, 2015 and 2030
DALYs % total per 100 000 DALYs % total per 100 000 DALYs % total per 100 000
WORLD Population
TOTAL DALYs Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Poliomyelitis Tetanus Meningitis Japanese encephalitis Total
Population
TOTAL DALYs Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Poliomyelitis Tetanus Meningitis Japanese encephalitis Total
AFRICA (HIGH CHILD, HIGH ADULT MORTALITY) 2005 2015 335 459 111 419 571 880
162 560 000 733 354 178 867 38 555 60 711 206 278 1 923 353 8 389 1 618 496 387 081 0 5 155 084 0.45 0.11 0.02 0.04 0.13 1.18 0.01 1.00 0.24 0.00 3.17 218.61 53.32 11.49 18.10 61.49 573.35 2.50 482.47 115.39 0.00 1 536.73 177 805 056 885 376 221 661 47 146 78 674 255 460 2 456 636 3 669 1 556 776 380 001 0 5 885 400 0.50 0.12 0.03 0.04 0.14 1.38 0.00 0.88 0.21 0.00 3.31 211.02 52.83 11.24 18.75 60.89 585.51 0.87 371.04 90.57 0.00 1 402.72
238.68 49.31 11.24 12.51 69.93 546.05 0.71 307.48 125.50 0.00 1 361.41
222.84 48.76 10.47 13.04 67.18 529.94 0.23 234.75 89.55 0.00 1 216.77
202.42 47.66 10.63 13.83 62.27 547.65 0.04 143.65 52.32 0.00 1 080.48
190
50.84 401.99 75.09 35.26 148.86 490.69 0.74 0.01 10.71 0.00 1 214.18
47.17 438.88 77.03 33.24 141.26 461.22 0.60 0.01 6.23 0.00 1 205.62
42.49 557.34 80.14 30.00 135.39 423.61 0.46 0.01 2.97 0.00 1 272.41
162.23 152.18 12.21 23.16 164.11 555.93 0.90 1.17 63.68 0.00 1 135.56
149.70 179.27 13.14 22.43 153.19 545.51 0.32 0.56 29.51 0.00 1 093.63
131.34 249.54 14.84 20.91 135.67 558.73 0.07 0.22 10.33 0.00 1 121.64
189.42 105.68 9.95 21.23 199.44 395.35 0.81 8.84 320.37 0.00 1 251.09
178.63 114.49 10.35 21.40 184.04 412.66 0.28 5.04 186.63 0.00 1 113.53
157.87 145.84 12.26 20.70 160.42 452.22 0.06 2.04 79.40 0.00 1 030.81
117.05 129.55 12.40 20.97 110.00 570.12 2.09 61.67 58.18 7.66 1 089.68
100.57 157.13 13.14 20.04 97.75 571.17 0.70 20.11 28.97 3.53 1 013.10
83.36 216.74 13.56 18.43 83.99 594.74 0.13 3.89 12.18 1.27 1 028.29
annexes
DALYs % total per 100 000 DALYs % total per 100 000 DALYs % total per 100 000
191
136.49 97.09 16.42 21.45 129.81 688.09 3.17 149.60 117.60 17.39 1 377.09
115.07 106.80 16.85 21.59 117.61 704.43 1.15 73.43 61.16 9.32 1 227.40
92.91 132.13 18.86 20.99 103.79 796.21 0.26 27.93 28.77 4.54 1 226.40
57.44 500.34 69.85 37.06 172.65 612.63 0.27 0.10 13.18 0.00 1 463.53
52.74 579.73 71.98 34.61 160.52 571.86 0.20 0.07 7.21 0.00 1 478.94
46.92 698.28 73.57 30.60 145.84 529.10 0.14 0.05 3.45 0.00 1 527.95
82.69 183.33 30.46 27.90 110.36 1 121.30 0.50 0.77 108.02 0.00 1 665.33
76.43 202.82 30.02 26.47 98.60 1 059.80 0.18 0.31 47.92 0.00 1 542.55
67.20 247.37 31.14 24.05 85.28 1 060.78 0.04 0.10 16.64 0.00 1 532.60
73.67 232.40 37.86 35.61 95.87 2 419.18 0.07 0.17 25.40 0.00 2 920.22
64.17 270.17 35.86 33.17 84.85 2 330.23 0.04 0.11 13.12 0.00 2 831.72
54.01 326.04 34.25 29.09 72.83 2 118.91 0.02 0.08 5.82 0.00 2 641.05
192
81.94 72.95 27.27 24.90 87.45 405.30 2.04 2.45 46.20 0.00 750.50
72.91 81.52 25.56 23.82 78.28 408.57 0.68 1.03 20.09 0.00 712.46
63.42 112.27 25.96 22.42 65.06 465.88 0.13 0.26 6.34 0.00 761.74
133.66 67.40 16.12 20.68 113.38 541.12 2.53 290.18 275.84 19.48 1 480.39
119.27 70.14 14.90 20.78 110.19 519.24 0.90 179.74 168.74 11.59 1 215.49
100.58 79.79 14.47 21.25 100.30 529.25 0.19 82.26 75.62 5.03 1 008.75
40.22 535.08 75.60 18.36 91.73 775.72 0.22 0.03 6.16 0.16 1 543.28
36.91 680.27 76.89 17.10 82.64 738.36 0.15 0.03 3.74 0.07 1 636.16
33.16 843.52 73.10 15.59 77.11 653.74 0.10 0.02 1.97 0.04 1 698.37
66.99 160.11 17.49 22.02 109.24 1 024.14 1.98 16.76 37.94 14.13 1 470.80
57.43 193.76 18.82 20.41 99.33 1 016.28 0.65 6.81 18.38 5.53 1 437.39
48.54 276.74 22.19 18.49 84.70 1 078.75 0.12 2.35 7.76 2.00 1 541.64
annexes
193
Table A.4.2 Burden of neurological disorders, in DALYs, by cause and country income category, projections for 2005, 2015 and 2030
DALYs % total per 100 000 DALYs % total per 100 000 DALYs % total per 100 000
LOW INCOME
Population TOTAL DALYs Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Poliomyelitis Tetanus Meningitis Japanese encephalitis Total 2005 2 698 990 297 863 355 456 4 272 843 0.49 2 447 944 0.28 407 152 0.05 542 866 0.06 3 075 717 0.36 17 881 426 2.07 68 690 0.01 6 169 162 0.71 3 865 716 0.45 350 279 0.04 39 081 794 4.53 2005 2 267 665 265 396 248 352 1 813 961 0.46 3 417 084 0.86 446 605 0.11 527 563 0.13 2 421 814 0.61 24 063 276 6.07 36 435 0.01 245 781 0.06 1 159 835 0.29 203 368 0.05 34 335 721 8.67 2005 528 081 304 91 247 080 734 826 0.81 881 181 0.97 92 265 0.10 131 579 0.14 776 542 0.85 3 232 834 3.54 4 860 0.01 6 993 0.01 209 522 0.23 1 824 0.00 6 072 426 6.65 2005 947 138 427 118 750 184 486 287 0.41 4 331 265 3.65 670 491 0.56 307 679 0.26 1 385 579 1.17 5 606 824 4.72 5 180 0.00 673 0.00 101 685 0.09 5 563 0.00 12 901 225 10.86 2015 3 157 941 695 878 944 512 4 520 584 0.51 3 015 554 0.34 468 466 0.05 633 335 0.07 3 292 940 0.37 20 698 738 2.35 28 491 0.00 4 772 255 0.54 2 745 058 0.31 222 037 0.03 40 397 457 4.60 2015 2 394 506 774 390 254 624 1 698 068 0.44 4 263 380 1.09 482 673 0.12 518 073 0.13 2 324 256 0.60 24 385 588 6.25 12 774 0.00 93 989 0.02 618 082 0.16 78 458 0.02 34 475 340 8.83 2015 574 892 329 93 943 736 739 788 0.79 1 110 803 1.18 101 366 0.11 136 702 0.15 783 032 0.83 3 361 867 3.58 1 957 0.00 4 032 0.00 104 866 0.11 945 0.00 6 345 357 6.75 2015 975 884 050 118 245 712 460 841 0.39 5 149 842 4.36 709 829 0.60 297 810 0.25 1 335 981 1.13 5 368 321 4.54 3 723 0.00 489 0.00 59 427 0.05 2 680 0.00 13 388 941 11.32 2030 3 786 445 271 928 855 040 4 769 515 0.51 4 178 842 0.45 592 196 0.06 742 842 0.08 3 484 761 0.38 26 672 044 2.87 7 468 0.00 3 144 548 0.34 1 696 933 0.18 121 899 0.01 45 411 047 4.89 2030 2 504 674 883 388 888 288 1 542 638 0.40 6 133 343 1.58 560 720 0.14 493 924 0.13 2 085 111 0.54 25 586 734 6.58 2 574 0.00 26 771 0.01 270 382 0.07 26 320 0.01 36 728 516 9.44 2030 622 970 241 96 092 552 704 562 0.73 1 586 853 1.65 114 497 0.12 135 916 0.14 744 397 0.77 3 570 041 3.72 499 0.00 1 959 0.00 41 624 0.04 405 0.00 6 900 753 7.18 2030 1 002 892 462 112 894 104 424 689 0.38 6 495 107 5.75 747 640 0.66 275 597 0.24 1 281 723 1.14 5 034 698 4.46 2 719 0.00 353 0.00 29 921 0.03 1 303 0.00 14 293 750 12.66
158.31 90.70 15.09 20.11 113.96 662.52 2.55 228.57 143.23 12.98 1 448.02
143.15 95.49 14.83 20.06 104.27 655.45 0.90 151.12 86.93 7.03 1 279.23
125.96 110.36 15.64 19.62 92.03 704.41 0.20 83.05 44.82 3.22 1 199.31
79.99 150.69 19.69 23.26 106.80 1 061.15 1.61 10.84 51.15 8.97 1 514.14
70.92 178.05 20.16 21.64 97.07 1 018.40 0.53 3.93 25.81 3.28 1 439.77
61.59 244.88 22.39 19.72 83.25 1 021.56 0.10 1.07 10.80 1.05 1 466.40
139.15 166.86 17.47 24.92 147.05 612.18 0.92 1.32 39.68 0.35 1 149.90
128.68 193.22 17.63 23.78 136.20 584.78 0.34 0.70 18.24 0.16 1 103.75
113.10 254.72 18.38 21.82 119.49 573.07 0.08 0.31 6.68 0.07 1 107.72
HIGH INCOME
Population TOTAL DALYs Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Poliomyelitis Tetanus Meningitis Japanese encephalitis Total
51.34 457.30 70.79 32.49 146.29 591.98 0.55 0.07 10.74 0.59 1 362.13
47.22 527.71 72.74 30.52 136.90 550.10 0.38 0.05 6.09 0.27 1 371.98
42.35 647.64 74.55 27.48 127.80 502.02 0.27 0.04 2.98 0.13 1 425.25
194
Table A.4.3 Deaths attributable to neurological disorders, by cause, WHO region and mortality stratum, projections for 2005, 2015 and 2030
Deaths % total per 100 000 Deaths % total per 100 000 Deaths % total per 100 000
WORLD
2005 Population TOTAL DALYs Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Poliomyelitis Tetanus Meningitis Japanese encephalitis Total 6 441 919 466 58 028 152 126 096 0.22 425 331 0.73 105 012 0.18 16 275 0.03 0 0.00 5 745 748 9.90 774 0.00 191 592 0.33 152 004 0.26 11 625 0.02 6 774 457 11.67 2015 7 103 297 899 63 458 962 130 569 0.21 513 230 0.81 127 293 0.20 16 669 0.03 0 0.00 6 466 232 10.19 654 0.00 145 640 0.23 106 372 0.17 7 282 0.01 7 513 942 11.84 2030 7 917 115 397 73 247 767 139 276 0.19 671 372 0.92 165 418 0.23 17 012 0.02 0 0.00 7 787 656 10.63 577 0.00 95 587 0.13 69 946 0.10 4 318 0.01 8 951 162 12.22
1.96 6.60 1.63 0.25 0.00 89.19 0.01 2.97 2.36 0.18 105.16
1.84 7.23 1.79 0.23 0.00 91.03 0.01 2.05 1.50 0.10 105.78
1.76 8.48 2.09 0.21 0.00 98.36 0.01 1.21 0.88 0.05 113.06
5.72 1.03 0.78 0.04 0.00 55.68 0.01 14.21 2.45 0.00 79.92
5.64 1.05 0.80 0.04 0.00 57.42 0.00 10.94 1.96 0.00 77.85
5.61 1.07 0.82 0.05 0.00 61.98 0.00 6.50 1.31 0.00 77.33
5.51 1.04 0.77 0.05 0.00 53.30 0.00 9.10 2.94 0.00 72.71
5.22 1.06 0.79 0.04 0.00 53.37 0.00 6.96 2.14 0.00 69.58
4.99 1.02 0.77 0.04 0.00 54.13 0.00 4.27 1.35 0.00 66.57
0.54 32.50 5.93 1.09 0.00 56.03 0.11 0.00 0.35 0.00 96.55
0.50 33.27 6.30 1.05 0.00 53.92 0.10 0.00 0.25 0.00 95.39
0.46 41.25 7.78 0.95 0.00 58.81 0.09 0.00 0.18 0.00 109.52
annexes
195
Deaths
% total
Deaths
% total
Deaths
% total
1.30 2.69 0.92 0.19 0.00 53.49 0.00 0.05 1.51 0.00 60.16
1.23 3.12 1.07 0.21 0.00 55.82 0.00 0.03 0.80 0.00 62.27
1.13 3.98 1.42 0.23 0.00 66.40 0.00 0.02 0.38 0.00 73.56
2.02 0.77 0.90 0.05 0.00 36.62 0.00 0.28 9.87 0.00 50.52
1.94 0.79 0.96 0.05 0.00 38.54 0.00 0.17 5.97 0.00 48.41
1.81 0.95 1.20 0.05 0.00 45.23 0.00 0.07 2.87 0.00 52.19
1.63 3.19 0.50 0.05 0.00 55.93 0.00 1.86 2.61 0.06 65.83
1.38 4.10 0.64 0.05 0.00 64.13 0.00 0.62 1.60 0.04 72.57
1.14 5.38 0.85 0.06 0.00 75.52 0.00 0.13 0.97 0.02 84.07
2.04 6.38 0.71 0.09 0.00 71.21 0.01 4.49 4.15 0.53 89.61
1.68 7.12 0.79 0.09 0.00 76.46 0.01 2.22 2.50 0.31 91.17
1.35 8.66 0.96 0.10 0.00 91.26 0.00 0.86 1.49 0.17 104.86
196
1.45 24.53 5.63 0.97 0.00 98.17 0.04 0.02 0.48 0.00 131.30
1.44 29.39 6.93 0.95 0.00 102.41 0.03 0.01 0.34 0.00 141.51
1.37 33.55 7.91 0.86 0.00 102.12 0.03 0.01 0.24 0.00 146.08
1.82 1.57 0.81 0.60 0.00 131.27 0.00 0.04 3.41 0.00 139.53
1.73 1.65 0.82 0.58 0.00 138.60 0.00 0.02 1.65 0.00 145.06
1.61 1.76 0.88 0.60 0.00 144.15 0.00 0.01 0.71 0.00 149.73
1.83 2.72 0.64 0.97 0.00 325.31 0.00 0.02 1.12 0.00 332.62
1.56 2.96 0.70 0.89 0.00 363.83 0.00 0.01 0.65 0.00 370.61
1.28 3.10 0.73 0.77 0.00 361.35 0.00 0.01 0.37 0.00 367.60
1.23 1.45 1.20 0.18 0.00 38.84 0.00 0.07 1.22 0.00 44.20
1.11 1.69 1.25 0.19 0.00 41.06 0.00 0.03 0.58 0.00 45.90
1.04 2.26 1.52 0.21 0.00 52.03 0.00 0.01 0.23 0.00 57.30
annexes
Deaths % total per 100 000 Deaths % total per 100 000 Deaths % total per 100 000
197
2.24 2.60 0.43 0.13 0.00 48.00 0.00 8.67 5.63 0.56 68.26
1.95 2.70 0.43 0.13 0.00 48.94 0.00 5.39 3.44 0.34 63.32
1.61 3.16 0.48 0.13 0.00 54.01 0.00 2.49 1.56 0.15 63.59
0.56 7.11 3.03 0.14 0.00 98.59 0.02 0.01 0.26 0.00 109.72
0.56 9.37 3.91 0.15 0.00 114.10 0.02 0.01 0.22 0.00 128.34
0.54 12.70 4.74 0.16 0.00 120.27 0.02 0.01 0.18 0.00 138.61
1.10 3.82 1.74 0.07 0.00 117.15 0.00 0.51 1.00 0.13 125.53
0.96 4.58 1.98 0.08 0.00 122.62 0.00 0.22 0.55 0.05 131.02
0.83 6.02 2.62 0.08 0.00 146.39 0.00 0.08 0.30 0.02 156.34
198
Table A.4.4 Deaths attributable to neurological disorders, by cause and country income category, projections for 2005, 2015 and 2030
Deaths % total per 100 000 Deaths % total per 100 000 Deaths % total per 100 000
LOW INCOME
Population TOTAL DALYs Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Poliomyelitis Tetanus Meningitis Japanese encephalitis Total 2005 2 698 990 297 28 672 778 79 248 0.28 117 006 0.41 18 481 0.06 2 557 0.01 0 0.00 1 839 308 6.41 177 0.00 183 622 0.64 110 589 0.39 10 003 0.03 2 360 989 8.23 2005 2 267 665 265 17 652 714 30 565 0.17 60 684 0.34 31 952 0.18 4 124 0.02 0 0.00 2 791 658 15.81 12 0.00 7 584 0.04 32 066 0.18 1 620 0.01 2 960 266 16.77 2005 528 081 304 3 566 059 7 115 0.20 16 506 0.46 5 439 0.15 1 736 0.05 0 0.00 343 741 9.64 16 0.00 284 0.01 5 750 0.16 1 0.00 380 587 10.67 2005 947 138 427 8 136 260 9 168 0.11 231 134 2.84 49 139 0.60 7 857 0.10 0 0.00 771 010 9.48 570 0.01 103 0.00 3 595 0.04 1 0.00 1 072 577 13.18 2015 3 157 941 695 30 854 969 85 525 0.28 147 611 0.48 23 210 0.08 2 848 0.01 0 0.00 2 212 111 7.17 108 0.00 142 332 0.46 81 490 0.26 6 800 0.02 2 702 035 8.76 2015 2 394 506 774 19 527 556 28 746 0.15 74 768 0.38 38 119 0.20 4 088 0.02 0 0.00 3 045 869 15.60 8 0.00 3 027 0.02 18 680 0.10 481 0.00 3 213 785 16.46 2015 574 892 329 4 137 547 7 168 0.17 20 434 0.49 6 807 0.16 1 796 0.04 0 0.00 389 884 9.42 12 0.00 190 0.00 3 481 0.08 0 0.00 429 773 10.39 2015 975 884 050 8 938 508 9 129 0.10 270 416 3.03 59 155 0.66 7 938 0.09 0 0.00 818 338 9.16 527 0.01 90 0.00 2 718 0.03 1 0.00 1 168 312 13.07 2030 3 786 445 271 35 900 272 96 579 0.27 203 293 0.57 31 322 0.09 3 377 0.01 0 0.00 2 926 235 8.15 53 0.00 94 390 0.26 55 933 0.16 4 209 0.01 3 415 391 9.51 2030 2 504 674 883 22 973 178 26 985 0.12 100 342 0.44 51 958 0.23 4 154 0.02 0 0.00 3 537 725 15.40 5 0.00 994 0.00 10 009 0.04 109 0.00 3 732 280 16.25 2030 622 970 241 4 903 171 6 984 0.14 27 069 0.55 9 432 0.19 1 909 0.04 0 0.00 464 680 9.48 7 0.00 124 0.00 2 013 0.04 0 0.00 512 219 10.45 2030 1 002 892 462 9 470 662 8 725 0.09 340 667 3.60 72 704 0.77 7 572 0.08 0 0.00 858 977 9.07 512 0.01 78 0.00 1 988 0.02 1 0.00 1 291 225 13.63
2.94 4.34 0.68 0.09 0.00 68.15 0.01 6.80 4.10 0.37 87.48
2.71 4.67 0.73 0.09 0.00 70.05 0.00 4.51 2.58 0.22 85.56
2.55 5.37 0.83 0.09 0.00 77.28 0.00 2.49 1.48 0.11 90.20
1.35 2.68 1.41 0.18 0.00 123.11 0.00 0.33 1.41 0.07 130.54
1.20 3.12 1.59 0.17 0.00 127.20 0.00 0.13 0.78 0.02 134.21
1.08 4.01 2.07 0.17 0.00 141.24 0.00 0.04 0.40 0.00 149.01
1.35 3.13 1.03 0.33 0.00 65.09 0.00 0.05 1.09 0.00 72.07
1.25 3.55 1.18 0.31 0.00 67.82 0.00 0.03 0.61 0.00 74.76
1.12 4.35 1.51 0.31 0.00 74.59 0.00 0.02 0.32 0.00 82.22
HIGH INCOME
Population TOTAL DALYs Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Poliomyelitis Tetanus Meningitis Japanese encephalitis Total
0.97 24.40 5.19 0.83 0.00 81.40 0.06 0.01 0.38 0.00 113.24
0.94 27.71 6.06 0.81 0.00 83.86 0.05 0.01 0.28 0.00 119.72
0.87 33.97 7.25 0.76 0.00 85.65 0.05 0.01 0.20 0.00 128.75
annexes
199
Table A.4.5 Burden of neurological disorders, in YLDs, by cause, WHO region and mortality stratum, projections for 2005, 2015 and 2030
YLDs % total per 100 000 YLDs % total per 100 000 YLDs % total per 100 000
WORLD
2005 Population TOTAL DALYs Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Neuroinfections Nutritional and neuropathies Neurological injuries Total 6 441 919 466 570 766 387 4 167 285 0.73 9 494 517 1.66 1 137 991 0.20 1 286 458 0.23 7 659 687 1.34 11 389 442 2.00 6 337 373 1.11 12 557 068 2.20 27 402 985 4.80 81 432 806 14.27 2015 7 103 297 899 592 406 432 4 323 495 0.73 11 750 573 1.98 1 228 128 0.21 1 371 367 0.23 7 736 261 1.31 12 423 121 2.10 5 099 627 0.86 12 381 343 2.09 27 952 326 4.72 84 266 242 14.22 2030 7 917 115 397 620 989 911 4 402 862 0.71 16 144 423 2.60 1 353 366 0.22 1 453 083 0.23 7 596 089 1.22 14 073 668 2.27 3 613 205 0.58 10 603 690 1.71 28 566 683 4.60 87 807 069 14.14
64.69 147.39 17.67 19.97 118.90 176.80 98.38 194.93 425.39 1 264.11
60.87 165.42 17.29 19.31 108.91 174.89 71.79 174.30 393.51 1 186.30
55.61 203.92 17.09 18.35 95.95 177.76 45.64 133.93 360.82 1 109.08
84.43 44.89 7.48 17.31 61.49 60.11 561.41 367.93 594.12 1 799.17
81.12 44.68 7.25 17.97 60.89 61.59 426.03 307.03 597.44 1 603.99
71.25 47.14 7.90 18.39 57.43 70.22 252.40 217.82 596.49 1 339.03
106.90 40.98 7.25 11.64 69.93 51.69 495.50 468.37 420.30 1 672.55
100.37 40.86 6.57 12.23 67.18 49.92 373.66 371.20 422.37 1 444.37
90.25 40.34 6.87 13.05 62.27 53.37 224.70 246.89 434.08 1 171.83
41.60 319.89 56.33 21.81 148.86 233.24 15.53 127.87 183.44 1 148.58
39.12 354.76 57.30 20.99 141.26 226.81 7.68 205.27 155.42 1 208.61
36.02 455.25 56.39 20.23 135.39 206.21 2.89 175.14 122.67 1 210.19
200
132.02 140.69 7.96 20.62 164.11 149.07 50.03 99.42 671.21 1 435.13
123.31 166.96 8.44 19.90 153.19 156.06 24.22 123.24 646.76 1 422.09
110.03 234.87 8.93 18.47 135.67 167.07 10.38 110.62 611.46 1 407.50
138.42 100.70 5.22 20.39 199.44 77.09 69.02 122.00 488.77 1 221.06
131.72 109.51 5.31 20.53 184.04 83.98 39.06 134.61 469.60 1 178.38
117.96 140.45 5.79 19.83 160.42 97.92 16.25 113.60 426.43 1 098.65
74.71 111.08 9.64 20.32 110.00 116.16 48.24 228.38 375.55 1 094.07
67.95 137.01 10.04 19.41 97.75 124.02 19.43 193.05 338.80 1 007.46
60.16 192.92 9.69 17.82 83.99 139.19 6.40 146.73 289.80 946.71
76.53 70.01 13.36 20.02 129.81 125.19 49.56 221.47 543.81 1 249.76
68.75 78.39 13.63 20.24 117.61 132.17 25.60 168.19 485.66 1 110.25
59.62 97.78 15.01 19.71 103.79 153.95 11.22 120.73 421.85 1 003.65
annexes
YLDs % total per 100 000 YLDs % total per 100 000 YLDs % total per 100 000
201
37.30 431.58 51.45 25.38 172.65 230.75 18.10 67.47 149.89 1 184.58
35.17 504.13 51.50 23.87 160.52 220.71 13.65 73.09 123.88 1 206.53
32.60 614.36 50.78 21.95 145.84 210.21 11.35 65.35 93.40 1 245.84
38.34 167.13 22.83 20.14 110.36 234.93 23.27 159.62 309.13 1 085.75
35.68 187.29 22.75 19.54 98.60 232.91 13.23 116.72 263.23 989.95
32.12 232.45 24.03 17.93 85.28 246.58 7.34 84.43 208.62 938.78
33.28 206.91 32.73 18.73 95.87 434.44 11.91 198.00 595.27 1 627.15
30.36 246.67 31.05 18.09 84.85 426.43 10.83 152.05 532.53 1 532.85
27.30 304.52 29.71 16.64 72.83 407.78 11.10 99.23 474.71 1 443.81
50.70 64.53 10.34 21.73 87.45 99.70 29.54 197.62 684.15 1 245.77
47.26 72.83 10.88 20.90 78.28 108.35 12.25 179.78 594.94 1 125.46
43.08 101.47 12.44 19.66 65.06 129.07 3.44 146.05 498.31 1 018.58
202
68.43 55.51 11.61 19.10 113.38 78.16 157.85 370.42 576.88 1 451.34
64.37 58.26 10.78 19.27 110.19 78.77 98.45 288.35 548.41 1 276.86
58.46 66.30 10.64 19.77 100.30 86.79 46.73 194.16 514.84 1 097.98
30.23 514.02 64.33 16.73 91.73 354.32 23.21 88.54 132.83 1 315.95
28.19 655.51 64.16 15.52 82.64 338.66 21.64 88.74 110.73 1 405.78
26.03 813.21 59.31 14.13 77.11 302.68 21.70 78.48 83.91 1 476.56
39.70 142.35 8.43 20.91 109.24 240.77 34.32 115.48 309.43 1 020.62
35.24 174.67 9.40 19.34 99.33 255.76 13.87 108.21 262.18 978.01
31.25 253.92 10.51 17.52 84.70 277.34 4.99 84.07 210.83 975.13
annexes
203
Table A.4.6 Burden of neurological disorders, in YLDs, by cause and country income category, projections for 2005, 2015 and 2030
YLDs % total per 100 000 YLDs % total per 100 000 YLDs % total per 100 000
LOW INCOME
Population TOTAL DALYs Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Neuroinfections Nutritional and neuropathies Neurological Injuries Total 2005 2 698 990 297 274 869 775 2 162 379 0.79 1 887 847 0.69 308 756 0.11 501 366 0.18 3 075 717 1.12 2 961 840 1.08 5 178 007 1.88 7 806 618 2.84 13 836 513 5.03 37 719 043 13.72 2005 2 267 665 265 180 841 215 1 083 085 0.60 3 092 955 1.71 255 194 0.14 464 515 0.26 2 421 813 1.34 5 256 334 2.91 773 549 0.43 3 277 499 1.81 9 200 404 5.09 25 825 349 14.28 2005 528 081 304 48 512 303 574 453 1.18 804 632 1.66 66 408 0.14 108 140 0.22 776 542 1.60 841 607 1.73 207 991 0.43 540 532 1.11 2 831 533 5.84 6 751 839 13.92 2005 947 138 427 66 539 151 347 335 0.52 3 709 039 5.57 507 626 0.76 212 428 0.32 1 385 579 2.08 2 329 596 3.50 177 788 0.27 932 307 1.40 1 534 400 2.31 11 136 099 16.74 2015 3 157 941 695 296 212 785 2 345 818 0.79 2 358 215 0.80 353 265 0.12 590 060 0.20 3 292 940 1.11 3 497 473 1.18 4 484 971 1.51 7 321 821 2.47 15 166 127 5.12 39 410 691 13.30 2015 2 394 506 774 179 114 557 1 051 524 0.59 3 912 760 2.18 277 039 0.15 460 503 0.26 2 324 256 1.30 5 698 033 3.18 370 936 0.21 3 045 262 1.70 8 521 185 4.76 25 661 498 14.33 2015 574 892 329 50 027 602 588 084 1.18 1 025 454 2.05 71 217 0.14 113 803 0.23 783 032 1.57 925 989 1.85 115 195 0.23 707 179 1.41 2 954 590 5.91 7 284 542 14.56 2015 975 884 050 67 046 328 338 021 0.50 4 454 081 6.64 526 601 0.79 206 989 0.31 1 335 981 1.99 2 301 556 3.43 128 477 0.19 1 306 923 1.95 1 310 269 1.95 11 908 897 17.76 2030 3 786 445 271 327 825 374 2 508 911 0.77 3 298 981 1.01 441 287 0.13 696 371 0.21 3 484 761 1.06 4 623 403 1.41 3 295 399 1.01 6 284 158 1.92 16 970 828 5.18 41 604 099 12.69 2030 2 504 674 883 176 548 919 996 999 0.56 5 720 544 3.24 307 805 0.17 443 061 0.25 2 085 110 1.18 6 238 042 3.53 159 203 0.09 2 424 744 1.37 7 594 651 4.30 25 970 159 14.71 2030 622 970 241 51 204 031 573 146 1.12 1 483 308 2.90 75 045 0.15 114 563 0.22 744 397 1.45 1 030 004 2.01 60 222 0.12 698 714 1.36 2 963 659 5.79 7 743 058 15.12 2030 1 002 892 462 65 404 060 323 722 0.49 5 641 486 8.63 529 223 0.81 199 064 0.30 1 281 723 1.96 2 182 130 3.34 98 343 0.15 1 195 901 1.83 1 037 296 1.59 12 488 887 19.09
80.12 69.95 11.44 18.58 113.96 109.74 191.85 289.24 512.66 1 397.52
74.28 74.68 11.19 18.68 104.27 110.75 142.02 231.85 480.25 1 247.99
66.26 87.13 11.65 18.39 92.03 122.10 87.03 165.96 448.20 1 098.76
47.76 136.39 11.25 20.48 106.80 231.79 34.11 144.53 405.72 1 138.85
43.91 163.41 11.57 19.23 97.07 237.96 15.49 127.18 355.86 1 071.68
39.81 228.39 12.29 17.69 83.25 249.06 6.36 96.81 303.22 1 036.87
108.78 152.37 12.58 20.48 147.05 159.37 39.39 102.36 536.19 1 278.56
102.29 178.37 12.39 19.80 136.20 161.07 20.04 123.01 513.94 1 267.11
92.00 238.10 12.05 18.39 119.49 165.34 9.67 112.16 475.73 1 242.93
HIGH INCOME
Population TOTAL DALYs Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Neuroinfections Nutritional and neuropathies Neurological Injuries Total
36.67 391.60 53.60 22.43 146.29 245.96 18.77 98.43 162.00 1 175.76
34.64 456.41 53.96 21.21 136.90 235.84 13.17 133.92 134.26 1 220.32
32.28 562.52 52.77 19.85 127.80 217.58 9.81 119.25 103.43 1 245.29
204
Table A.4.7 Prevalence (per 1000) of neurological disorders, by cause, WHO region and mortality stratum, projections for 2005, 2015 and 2030
Number per 1 000 WORLD
2005 Population Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Neuroinfections Nutritional and neuropathies Neurological injuries 6 441 919 466 39 891 898 24 446 651 5 223 897 2 492 385 326 196 121 61 537 499 18 169 479 352 494 535 170 382 211 6.19 3.79 0.81 0.39 50.64 9.55 2.82 54.72 26.45 2015 7 103 297 899 44 568 780 31 318 923 5 967 673 2 823 092 364 432 879 67 212 050 15 714 399 321 738 424 197 627 526 6.27 4.41 0.84 0.40 51.30 9.46 2.21 45.29 27.82 2030 7 917 115 397 50 503 933 44 016 718 7 236 712 3 279 199 412 894 420 76 826 249 13 290 180 285 369 403 242 728 912 6.38 5.56 0.91 0.41 52.15 9.70 1.68 36.04 30.66
Number
per 1 000
Number
per 1 000
annexes
205
Prevalence (per 1000) of neurological disorders by cause by WHO region and mortality stratum projections for 2005 2015 and 2030
Number per 1 000
2005 Population Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Neuroinfections Nutritional and neuropathies Neurological injuries 463 707 779 5 995 062 1 563 720 131 149 169 790 26 424 577 3 579 817 1 130 487 10 977 028 18 428 772 12.93 3.37 0.28 0.37 56.99 7.72 2.44 23.67 39.74
Number
per 1 000
2015
Number
per 1 000
2030
206
Number
per 1 000
2015
Number
per 1 000
2030
annexes
Number per 1 000
2005 Population Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Neuroinfections Nutritional and neuropathies Neurological injuries 388 102 585 2 307 484 433 980 153 850 118 755 12 122 159 1 449 886 2 040 970 29 803 040 14 044 340 5.95 1.12 0.40 0.31 31.23 3.74 5.26 76.79 36.19
207
Number
per 1 000
2015
Number
per 1 000
2030
208
Table A.4.8 Prevalence (per 1000) of neurological disorders, by cause and country income category, projections for 2005, 2015 and 2030
Number per 1 000 Number per 1 000 Number per 1 000 LOW INCOME 2005 2 698 990 297
18 767 673 4 187 247 1 026 261 861 399 97 386 421 14 233 869 12 219 114 229 490 905 90 262 196 6.95 1.55 0.38 0.32 36.08 5.27 4.53 85.03 33.44
Population
Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Neuroinfections Nutritional and neuropathies Neurological Injuries
Population
Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Neuroinfections Nutritional and neuropathies Neurological Injuries
LOWER MIDDLE INCOME 2005 2015 2 267 665 265 2 394 506 774
10 651 319 7 498 331 1 016 623 905 993 104 870 967 27 616 112 3 822 412 89 556 278 54 090 897 4.70 3.31 0.45 0.40 46.25 12.18 1.69 39.49 23.85 11 308 222 9 730 403 1 134 671 997 151 115 096 758 30 176 588 2 835 263 73 313 524 59 112 199 4.72 4.06 0.47 0.42 48.07 12.60 1.18 30.62 24.69
Population
Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Neuroinfections Nutritional and neuropathies Neurological Injuries
Population
Epilepsy Alzheimer and other dementias Parkinsons disease Multiple sclerosis Migraine Cerebrovascular disease Neuroinfections Nutritional and neuropathies Neurological Injuries
annexes
209
Annex 5
Contact details
Pediatric Neurology University of Rome Tor Vergata P. le Umanesimo 10 144 Rome Italy tel: +39 335 834 89 21 fax:+39 06 941 14 63 e-mail: curatolo@uniroma2.it web site: http://www.child-neuro.net
The general purpose of ICNA is: to create a non-prot association of child neurologists and members of allied professions from all parts of the world dedicated to promoting clinical and scientic research in the eld of child neurology and encouraging the recognition of child neurologists competence and scope of practice; to provide, at an international level, an outlet for interchange of scientic and professional opinions for the benet and advancement of the neurological sciences in infancy and childhood; to establish international scientic meetings, international cooperative studies, publications, translations, audio-visual material and to encourage international exchange of teachers and students in the eld of child neurology. It is the purpose of WFN to improve human health worldwide by promoting prevention and the care of persons with disorders of the entire nervous system by: fostering the best standards of neurological practice; educating, in collaboration with neuroscience and other international public and private organizations; facilitating research through its Research Groups and other means. EFNS is an organization that unites and supports neurologists across the whole of Europe. It aims: to broaden the base of clinical neurology in Europe; raise public awareness about the importance of the brain and its disorders; to strengthen the standard, availability and uniformity of neurological services in Europe; to create and maintain continuing medical education guidelines and accreditation; support and encourage European clinical neuroscience research programmes; to strengthen the standard, quantity and equality of pre-graduate and postgraduate teaching and training; to strengthen WFN, EU and WHO relations; to strengthen collaboration with related professional and lay organizations; organize European Neurology Congresses and Neurological Teaching Courses; to publish the European Journal of Neurology. The aims of ENS are to provide continuing education in all elds of neurology, to create a scientic forum for the presentation of original research work for all the neurologists, to guarantee a high level of scientic standard, and to support the younger generation by continuing promotions such as travel grants, fellowships stipends or the new neurologist in training offer.
12 Chandos Street London W1G 9DR England tel: +44 20 7323 4011 fax:+44 20 7323 4012 e-mail: WFNLondon@aol.com web site: http://www.wfneurology.org EFNS Head Ofce Breite Gasse 48 1070 Vienna Austria tel: +43 1 889 05 03 fax: +43 1 889 05 03 13 e-mail: headofce@efns.org web site: http://www.efns.org
ENS Administrative Secretariat c/o AKM Congress Service P.O. Box 4005 Basel Switzerland tel: +41 61 686 77 77 fax: +41 61 686 77 88 e-mail: info@akm.ch web site: http://www.ensinfo.com
210
EPILEPSY International Bureau for Epilepsy (IBE) International Bureau for Epilepsy Unit 4 Hillview House Bracken Road Sandyford Dublin 18 Ireland tel: +353 1 293 4961 fax: +353 1 293 4963 e-mail: ibedublin@eircom.net web site: http://www.ibe-epilepsy.org 204 avenue Marcel Thiry 1200 Brussels Belgium tel: + 32 (0) 2 774 9547 fax: + 32 (0) 2 774 9690 e-mail: dsartiux@ilae.org web site: http://www.ilae-epilepsy.org IBE is an organization of lay persons and professionals interested in the medical and non-medical aspects of epilepsy. It addresses such social problems as education, employment, insurance, driving-licence restrictions and public awareness. It provides assistance by offering international support, by creating means for worldwide exchange of information and, where possible, by setting standards that provide an international policy focus and identity for all persons with epilepsy. IBE works in close liaison with the International League against Epilepsy.
ILAE is the worlds pre-eminent association of physicians and other health professionals working towards a world where no persons life is limited by epilepsy. Its mission is to provide the highest quality of care and wellbeing for those aficted with the condition and other related seizure disorders. The League aims to advance and disseminate knowledge about epilepsy, to promote research, education and training and to improve services and care for patients, especially by prevention, diagnosis and treatment.
HEADACHE DISORDERS International Headache Society (IHS) c/o Grifn Stone, Moscrop and Co. 41 Welbeck Street London W1G 8EA England e-mail: info@i-h-s.org web site: http:// www.i-h-s.org c/o Grifn Stone, Moscrop and Co 41 Welbeck Street London W1G 8EA England e-mail: info@w-h-a.org web site: http://www.w-h-a.org A worldwide professional society, the mission of IHS is to work with others to reduce the world burden of headache. The web site includes all published guidelines and recommendations of the IHS, and professional educational pages are planned.
A worldwide lay alliance, WHA exists to relieve the suffering of people affected by headache throughout the world, in particular by sharing information among headache organizations and by increasing the awareness and understanding of headache as a public health concern with profound social and economic impact. The web site includes a regularly updated source of detailed and quality-controlled information on headache for the general public, with many useful links. A European professional federation, EHF dedicates its efforts to improving awareness among governments, health-care providers and consumers across Europe of headache disorders and their personal and socioeconomic impact. Ultimately EHF seeks to create the optimal environment for headache sufferers and their carers across all Europe, so that they have access to appropriate treatment and therefore enjoy a better quality of life.
c/o Kenes International 17 rue du Cendrier PO Box 1726 1211 Geneva 1 Switzerland. tel: +41 22 906 9154 fax: +41 22 732 2852 e-mail: info@ehf-org.org web site: http://www.ehf-org.org
annexes
Organization MULTIPLE SCLEROSIS Multiple Sclerosis International Federation (MSIF) 200 Union Street London SE1 0LX England tel: +44 20 7620 1911 fax: +44 20 7620 1922 e-mail: info@msif.org web site: http://www.msif.org MSIF was established in 1967 as an international body linking the activities of national multiple sclerosis societies around the world. MSIF seeks to work in worldwide partnership with member societies and the international scientic community to eliminate multiple sclerosis and its consequences, and to speak out globally on behalf of those affected by multiple sclerosis. MSIF works to achieve this through the following key priorities: international research; development of new and existing societies; exchange of information; advocacy. The mission of EMSP is to exchange and disseminate information relating to multiple sclerosis, considering all issues relevant to people affected by it: to encourage research of all kinds that is appropriate to multiple sclerosis through recognized medical and other organizations; to promote the development of joint action programmes with the participation of national multiple sclerosis societies in Europe, aimed at improving the quality of their activities and services; to act as focal point for liaison with the institutions of the European Union, the Council of Europe and other European organizations, in order to study and propose measures to improve the autonomy of handicapped persons and promote their full participation in society. Contact details Mission statement, scope of activity or purpose
211
144/8 rue Auguste Lambiotte 1030 Brussels Belgium tel: +32 2 305 80 12 fax: +32 2 305 80 11 e-mail: ms-in-europe@pandora.be web site: http://www.ms-in-europe.com
PAIN ASSOCIATED WITH NEUROLOGICAL DISORDERS The International Association for the Study of Pain (IASP) Queen Anne Avenue N, Suite 501 Seattle, WA 98109 4955 United States of America tel: +1 206 283 0311 fax: +1 206 283 9403 e-mail: iaspdesk@iasp-pain.org web site: http://www.iasp-pain.org Mrs Sarah Wheeler Executive Ofcer Foukithidou 2 16343 Iliopoulis, Athens Greece tel: +30 210 992 6335 mobile: + 30 694 447 8978 fax: + 30 210 992 6382 e-mail: ec@internet.gr web site: http://www.ec.org To foster and encourage research of pain mechanisms and pain syndromes and to help improve the management of patients with acute and chronic pain by bringing together basic scientists, physicians and other health professionals of various disciplines and backgrounds who have an interest in pain research and management.
To promote research, education, and the clinical management of pain, to create a forum for European collaboration on pain issues and to encourage communication at a European level between IASP Chapters, and also with other bodies interested or involved in the elds of pain research and therapy.
PARKINSONS DISEASE Asian and Pacic Parkinsons Association (APPA) PO Box 12042 50766 Kuala Lumpur Malaysia tel: +603 2454648 fax: +603 2454649 e-mail.: appda@po.jaring.my The objectives of APPA are: to establish and operate projects rendering service to persons suffering from Parkinsons disease; to encourage and promote research and other activities relating to the prevention, diagnosis, causes and treatment of Parkinsons disease; to cooperate with all relevant public and private agencies in services for persons suffering from Parkinsons disease; to collect, compile and disseminate information on causes, prevention, research programmes and available aids to combat Parkinsons disease, and to carry on a vigorous general public education programme within this eld; generally to do what may be required to give effect and carry forward the purposes of APPA without discriminating against any person or organization because of race or religion. Formed in 1992, EPDA now has a membership of 36 European organizations and eight associates. It is non-political, non-religious and non-prot making, concerned with the health and welfare of people with Parkinsons disease and their families. Collaboration with European patient and neurological organizations, the European Commission, WHO, WFN and the pharmaceutical industry has resulted in the development of quality of life research projects, education materials and multidisciplinary conferences.
4 Golding Road Sevenoaks Kent TN13 3NJ England tel/fax: +44 17 3245 7683 e-mail: lizzie@epda.eu.com web site: http://www.epda.eu.com
212
index
213
Index
As all countries in the WHO Member States are included in Annex 1 (p. 1834), specic country references to the Annexes are not included in the index. A list of abbreviations used in the text can be found in page xi of the preface.
acetylsalicylic acid (aspirin) 78, 134, 159 acquired immunodeciency syndrome (AIDS) highly active antiretroviral therapy (HAART) 978 HIV linked tuberculosis 100 mortality strata 31 neurological complications 967 neurological immune restoration inammatory syndrome (NIRIS) 97 progression 96 Toxoplasma encephalitis 104 acyclovir 99 African trypanosomiasis (sleeping sickness) 1056 alcohol-related neurological disorders 1201 alcohol-related epilepsy 121 alcohol-related polyneuropathy 121 fetal alcohol syndrome 120 Wernickes encephalopathy 115, 121 Alzheimers disease see dementia Alzheimers Disease International (ADI) 210 American trypanosomiasis (Chagas disease) 105 amitriptyline 79 Anopheles mosquito 104 anticholinesterase therapies, AD 47 antiepileptic drugs (AEDs) 578, 79 antiretroviral agents 97 apolipoprotein E (apoE ) e4 43 artemisinin 104 Asian and Pacic Parkinsons Association (APPA) 211 aspirin see acetylsalicylic acid ataxic polyneuropathy syndromes 119 Atlas of Country Resources for Neurological Disorders, WHO/WFN 2, 147 Atlas of Epilepsy Care in the World 66
bacterial meningitis 1012 conjugate meningococcal vaccine 102 Bangkok Charter for Health Promotion in a Globalized World 10 BCG vaccination 101 behavioural and psychological symptoms of dementia (BPSD) 42 benzimidazole 107 beri-beri 115 beta-blockers 79 brain drain problem 23 brain haemorrhage see stroke brain ischaemia see stroke Brazil dementia case study 54 Trypanosoma control programme 105 burden of disease see global burden of disease
clopidogrel 159 Clostridium tetani 102 cluster headaches 72, 73 follow-up and referral 80 therapeutic intervention 79 cobalamine (vitamin B12) deciency 116 complex regional pain syndrome (CRPS) 12930 computerized tomography (CT) 151 Controlled Medications Programmes 134 Costa Rica, traumatic brain injury rehabilitation 170 country income groups 185 cretinism 11617 Cuba, oral polio vaccine 99 cycle helmet, wearing see motorcycle helmet, wearing cystic hydatidosis (echinococcosis) 1067 cysticercosis 1034
cassava 119 causes and cause categories death, attributable to neurological disorders 198 disability-adjusted life year (DALY) 18992, 193 global burden of disease 2930, 1868 neurological disorders 2930 prevalence of neurological disorders 208 stroke 152 traumatic brain injury (TBI) 168 viral encephalitis 98 years of healthy life lost to disability (YLD) 203 cerebral malaria 104 cerebrovascular disease, GBD sequelae and case denitions 186 Chagas disease 105 children developmental quotients vs nutrition 114 World Summit for Children 1990 117 cholinesterase inhibitors 46 chronic pain, signs and symptoms 132
data presentation 307 death, attributable to neurological disorders 30, 35 by cause 198 by country income category 198 projections 1947, 198 rates 36 by region 1947 delirium tremens 121 dementia Alzheimers Disease International (ADI) 210 anticholinesterase therapies, AD 47 background 423 care delivery 4950 case studies Brazil 54 India 55 Nigeria 55 course and outcome 434 10/66 Dementia Research Group: key ndings 47 disability 45 epidemiology and burden 446
214
falls, GBD sequelae and case denitions 187 fetal alcohol syndrome 120 res, GBD sequelae and case denitions 187 folate deciency 11516 food compounds, toxic 114
echinococcosis 1067 Echinococcus E. granulosus 1067 E. multilocularis 106 E. oligarthrus 106 E. vogeli 106 education and training see training epidemiology and burden 9 epilepsy Atlas of Epilepsy Care in the World 66 background 56 burden 5960 avertable 612 global 60 national 61 course and outcome 578 education and training programmes 64 etiology and risk factors 567 GBD sequelae and case denitions 186 Global Campaign Against Epilepsy, ILAE/IBE/WHO 65 incidence 58
Glasgow Coma Scale (GCS), brain injury 165 Glasgow Outcome Scale, brain injury disability 167 global burden of disease cause categories 2930, 1868 data presentation 30 GBD 1990 278 GBD 2000 28 GBD 2002 28 Global Burden of Disease (GBD) Study 1, 9, 279, 111 malnutrition 111 methodology 30 projections 289, 18992 sequelae 1868 see also disability-adjusted life year (DALY); years of healthy life lost to disability (YLD) Global Campaign Against Epilepsy (ILAE/ IBE/WHO) 656 Global Polio Eradication Initiative, WHO 99 Glossina spp. 105 goitre 11617
Haemophilus inuenzae type B 102 Harvard School of Public Health 1, 9, 27 headache disorders background 701, 130 barriers to care 756 classication 72 diagnosis 767 epidemiology and burden 745 European Headache Federation (EHF) 10 follow-up and referral 80 health-care policy 801 International Headache Society (IHS) 210 Lifting the Burden campaign, WHO 81 management 778 over-diagnosis 74 population-based epidemiological studies 71 primary 70, 72, 734 recommendations 82 research 81 secondary 70, 72, 74 therapeutic interventions 7880 trigger factors 778 World Headache Alliance (WHA) 210 see also specic headache types health, denition 8 health promotion denition 910 nature and scope 10 hemispherectomy 58 hemispherotomy 58 herpes simplex encephalitis (HSE) 989 high-density lipoprotein (HDL) 152 highly active antiretroviral therapy (HAART) 978 hippocampal sclerosis 57 historical perspective 13 human immunodeciency virus (HIV) see acquired immunodeciency syndrome (AIDS) human T-lymphotropic virus type I (HTLVI), HTLV-I associated myelopathy 120 hydatidosis 1067 hypothyroidism 117
ibuprofen 78, 134 income categories 31, 185 India, dementia case study 55 injuries, GBD sequelae and case denitions self-inicted 188 unintentional 188 International Association for the Study of Pain (IASP) 211 International Bureau for Epilepsy (IBE) 65, 210 International Child Neurology Association (ICNA) 209 International Classication of Functioning, Disability and Health (ICF) 16 International Headache Society (IHS) 210
index
International League Against Epilepsy (ILAE) 64, 210 European Epilepsy Academy (EUREPA) 64 Global Campaign Against Epilepsy (ILAE/IBE/WHO) 656 international nongovernmental organizations (NGOs) 20912 International Stroke Society (ISS) 212 iodine deciency disorders 11617 GBD sequelae and case denitions 187 iron deciency anaemia 11718 gross domestic product (GDP) loss 119 medication-overuse headache 72, 734 follow-up and referral 80 therapeutic intervention 79 megaloblastic anaemia 11516 meningitis 1012 GBD sequelae and case denitions 187 meningococcal disease 102 methysergide 79 metoclopramide 78 micronutrient deciencies 11418 iodine deciency disorders 11617 iron deciency anaemia 11718 selenium deciency 118 vitamin A deciency 11415 vitamin B complex deciencies 11516 zinc deciency 118 migraine etiology and symptoms 72 follow-up and referral 80 GBD sequelae and case denitions 186 menstruation-related 79 population-based epidemiological studies 70 therapeutic intervention 789 YLD 75 see also headache disorders Monitoring Trends and Determinants in Cardiovascular Disease (MONICA) 155 mortality acquired immunodeciency syndrome (AIDS) 31 death, attributable to neurological disorders 1947 epilepsy 59 premature mortality 278 prevalence of neurological disorders 2047 regional variation 1834 stroke 1567 traumatic brain injury (TBI) 1667 years of healthy life lost to disability (YLD) 199202 mortality strata 31, 183 by WHO region 1834 see also deaths motorcycle helmet, wearing 11, 12 multiple sclerosis (MS) autoimmune nature 85 benign MS 87 childhood MS 889 diagnosis and classication 85 etiology and risk factors 878 European Code of Good Practice 90 European Multiple Sclerosis Platform (EMSP) 211 GBD sequelae and case denitions 186 global and regional distribution 88 impacts 8990 McDonald criteria 856 Multiple Sclerosis International Federation (MSIF) 91, 211 neurorehabilitation 901 prevention and treatment 90 primary progressive MS 87 prognostic factors 87 progression patterns 86 quality of life issues 92 relapsing/remitting MS 86 research 923 secondary progressive MS 87 training 93 Multiple Sclerosis International Federation (MSIF) 91, 211 muscle rigidity pain 129 mycobacterial and other bacterial diseases 1002 see also specic diseases Mycobacterium leprae 101
215
K L
konzo 120
Lathyrus sativus 11920 Lennox-Gastaut syndrome 58 leprosy neuropathy 101 GBD sequelae and case denitions 187 multidrug therapy (MDT) 101 levodopa 1434 lithium therapy 80
National Institute for Clinical Excellence 91 Neisseria meningitidis 102 neurocysticercosis 1034 neuroinfections 95108 see also specic disorders neuroleptics 46 neurological disorders cause categories 2930 international nongovernmental organizations (NGOs) 20912 neurological immune restoration inammatory syndrome (NIRIS) 97 neuropathic pain 127, 1289 niacin (vitamin B3) deciency 115 Nigeria, dementia case study 55 nociceptive pain 127 nongovernmental organizations (NGOs), international 20912 non-steroidal anti-inammatory (NSAID) drugs 134
macronutrient deciency 112 magnetic resonance imaging (MRI) 151 malaria 104 GBD sequelae and case denitions 187 malnutrition-related neurological disorders background 111 developmental quotients vs nutrition, children 114 etiology, risk factors and burden 11112 GBD sequelae and case denitions 187 long-term effects 112 macronutrient deciency 112 micronutrient deciencies 11418 iodine deciency disorders 11617 iron deciency anaemia 11718 selenium deciency 118 vitamin A deciency 11415 vitamin B complex deciencies 11516 zinc deciency 118 nutrient deciency 112 prevention 1213 public health framework 123 recommendations 124 severe malnutrition, treatment of 11213 toxic food compounds 112 see also toxiconutritional disorders McDonald criteria, MS 856 McGill Pain Questionnaire, Short-Form 130
O P
Obasanjo, Olusegun (President of Nigeria) 123 opioids 134 beta-N-oxalylamino-L-alanine 119 oxamniquine 106 Oxfordshire Community Stroke Project classication 152
pain associated with neurological disorders chronic pain, signs and symptoms 132 complex regional pain syndrome (CRPS) 12930 Controlled Medications Programmes 134 disability and burden 133 European Federation of IASP-Chapters (EFIC) 211 European Parkinsons Disease Association (EPDA) 211 headache and facial pain 130 International Association for the Study of Pain (IASP) 211 management 1346 muscle rigidity pain 129 neuropathic pain 127, 1289 nociceptive pain 127 public health framework 1313 recommendations 137
216
Q R
quinine 104
rabies 100 recommendations for action 17982 decision-makers commitment 180 links to other sectors 182 national and international collaboration 1812 neurological care 181 priorities for research 182 public and professional awareness 180 rehabilitation 181 stigma and discrimination 180 regional variation death, attributable to neurological disorders 1947 disability-adjusted life year (DALY) 34, 18992 mortality strata 1834 multiple sclerosis 88 prevalence of neurological disorders 2047 traumatic brain injury 168 years of healthy life lost to disability (YLD) 199202 rehabilitation case-studies Giovanni 18 Juan 19 costs 1920 denition 1617 neurological disorders 1819 Rehab-CYCLE 1718 strategy 1718 risk assessment 1112 CVD Risk Management Package, WHO 12, 13 road trafc accidents GBD sequelae and case denitions 187 motorcycle helmet, wearing 11, 12 prevention 1712 Rotary International 99
salt iodization 117 Schistosoma S. haematobium 106 S. intercalatum 106 S. japonicum 106 S. mansoni 106 S. mekongi 106
index
217
Taenia solium 1034 Tanzania see United Republic of Tanzania tension-type headache 72, 73 follow-up and referral 80 therapeutic intervention 79 tetanus 1023 GBD sequelae and case denitions 186 neonatal 102 thiamine (vitamin B1) deciency 115 toxic food compounds 114 toxic optic neuropathy 120 toxiconutritional disorders alcohol-related neurological disorders 120 ataxic polyneuropathy syndromes 119 background 11819 spastic paraparesis syndromes 11920 toxic food compounds 114 toxic optic neuropathy 120 see also malnutrition-related neurological disorders Toxoplasma gondii 1045 toxoplasmosis 1045 AIDS-related encephalitis 104 training physicians 223 primary care providers 22 traumatic brain injury (TBI) acute management 16970 causes, regional variation 168 costs 171 denition and outcome 1645 diagnosis and classication 165 Glasgow Coma Scale (GCS) 165 triage 165 disability 167 Glasgow Outcome Scale 167 education 1723 etiology and risk factors 168 incidence 166 mortality rates 1667 prevalence 166 prevention of road trafc accidents 1712 recommendations 173 recovery 167 rehabilitation 170 case-study 171 research 173 World Federation of Neurosurgical Societies 212 tricyclic antidepressants 46 trigeminal autonomic cephalalgias 73 triptans 78 tropical myeloneuropathies see toxiconutritional disorders tropical spastic paraparesis 120 Trypanosoma T. brucei gambiense 105 T. brucei rhodesiense 105 T. cruzi 105 trypanosomiasis African (sleeping sickness) 1056 American (Chagas disease) 105 tsetse ies (Glossina spp.) 105
tuberculosis BCG vaccination 101 HIV link 100 international control strategy (DOTS) 101 International Standards for Tuberculosis Care 101 meningeal tuberculosis 1001
United Nations Childrens Fund (UNICEF) 99 United Nations Educational, Scientic and Cultural Organization (UNESCO) 64 United Nations Population Fund (UNFPA) 103 United Republic of Tanzania AIDS intensive prevention programmes 98 United States Centers for Disease Control and Prevention (CDC) 99
Expanded Programme on Immunization (EPI) 101 Global Campaign to Reduce the Burden of Headache Worldwide 81 Global Polio Eradication Initiative 99 leprosy multidrug therapy (MDT) 101 Member States 1834 Monitoring Trends and Determinants in Cardiovascular Disease (MONICA) 155 regions 31 responsibilities 12 Stop TB campaign 101 Working Group on Parkinsons Disease 146 World Health Report 2000 14 World Summit for Children 1990 117
vascular dementia (VaD) see dementia vidarabine 99 violence, GBD sequelae and case denitions 188 viral diseases 96100 see also specic diseases viral encephalitis causes 98 prevention 99 symptoms and sequelae 99 vitamin A deciency 11415 vitamin B complex deciencies 11516 folate 11516 vitamin B1 (thiamine) 115 vitamin B3 (niacin) 115 vitamin B6 (pyridoxine) 115 vitamin B12 (cobalamine) 116 vitamin C 118
years of healthy life lost to disability (YLD) 278, 30 by cause 203 estimates 367 by income category 37, 203 by mortality stratum 199202 neurological disorder groupings 31 projections 199202, 203 by region 199202 see also disability-adjusted life year (DALY); global burden of disease
war, GBD sequelae and case denitions 188 Wernickes encephalopathy alcohol-related 121 vitamin B1 deciency 115 West Nile virus 99 West syndrome 58 World Bank 1, 9, 27, 33, 357, 64 country income groups 185 World Federation of Neurology (WFN) 2, 209 World Federation of Neurosurgical Societies 212 World Headache Alliance (WHA) 81, 210 World Health Organization (WHO) Access to Controlled Medications Programme 134 Atlas of Country Resources for Neurological Disorders 2, 147 Charter for People with Parkinsons Disease 146 CVD Risk Management Package 12, 13
218